OPM recently asked FEHB plans for data on hospital readmissions.  Policymakers think that reducing readmissions is a key to improving health care quality, as reflected in this new NCQA report. As the FEHBlog has noted Medicare began to penalize hospitals for high readmission rates last month. Psychcentral reports on a new readmissions study conducted by the University of Wisconsin

The study found some significant associations between social environmental factors, and suggested some pathways by which these effects occur. Patients’ functional ability — their ability to take care of themselves — was influenced by their living arrangements and by the type and frequency of informal care they received. The greater the difference between the patients’ clinical condition and functional status, the greater the risk of rehospitalization.

Shocker. Family and other informal support systems help patients avoid hospital readmissions.

The AMA News reports that

A study in the Fall edition of Perspectives in Health Information Management found that of those who were willing to use a personal health record, 65% self-reported a high health literacy level. For those who were not willing to use a PHR, 38% self-reported a high level of health literacy.

Shocker. Only 7% of patients use a PHR, according to this study.

Doctors are interested in this study because PHR use is a factor that the government considers in deciding whether doctors and hospitals have lived up to bargain that they cut when they took free electronic health records from the government.

Under stage 2 of the Medicare incentive program for the meaningful use of electronic health records [which kicks in next year], physicians must ensure that at least 5% of their patients access, download or transmit their medical records. [Can you say Blue Button?] For stage 1, physicians were required to provide electronic copies of health records to at least 50% of those who requested them. Seventy percent of physicians who received incentive payments for stage 1 said they did not have any patient requests for records.

Personal health records containing actual medical records no doubt will be more useful than personal health records containing health plans claims data. The FEHBlog notes that his internist has a new electronic medical records system but he does not recall being offered a personal health record. The FEHBlog will inquire.

On a related note, Modern Healthcare reports that “the American Hospital Association T wants to work with the government to
ensure that the sellers of electronic health-record systems are
producing systems that comply with federal law and don’t lead healthcare
providers to submit bills that later get them in trouble.” Government Health IT reports on a Congressional hearing held today that was trigged by news reports about perceived hospital abuse of their free electronic medical record systems.

Happy Veterans’ Day (observed).  The Federal Benefits Open Season begins today, November 12, and will end on December 10, 2012 (subject to OPM’s right to extend the Open Season to account for unusual circumstances).

On Friday, OPM posted an immediate effective interim final rule  (“IFR”) that “allows agencies such as the Federal Emergency Management Agency (FEMA) to apply to OPM for authorization to offer FEHBP coverage to intermittent employees engaged in emergency response functions.” This IFR closes the loop on the IFR  released last summer extending FEHBP coverage to temporary federal employees who fight forest fires for the Interior Department. That IFR solicited suggestions on further expanding coverage to other first responders. Govexec.com also credits an online petition but the FEHBlog thinks that the wheels were in motion for this IFR before the online petition coinciding with last month’s “super storm” and its timing is attributable to the start of Open Season.

The AMA News reports on the Centers for Medicare and Medicaid Services final rule on Medicare Part B reimbursement to physicians for the 2013 calendar year. This rule is obviously a big deal to doctors as it features the doctor’s “fiscal cliff” — a 26.5% reimbursement cut attributable to the statutory sustainable rate of growth formula that Congress is expected to address in the lame duck session that begins tomorrow. The rule also includes a number of other features stemming from the ACA that will take effect in January:

The fee schedule includes other rate cuts to some physicians, such as
lower payments for multiple advanced imaging scans and penalties for not
submitting quality measurements to the Centers for Medicare &
Medicaid Services. But CMS also finalized additional hardship exemptions
the doctors can use to prevent pay reductions for not reporting
electronic prescribing activity, and it further limited the number of
physicians who will have their rates adjusted according to quality and
cost scores by a value-based payment modifier in 2015.

Finally, the FEHBlog was interested to read (in a Pittsburgh Post Gazette article) that a Pennsylvania state court judge on Friday granted Highmark a preliminary injunction against the West Penn Allegheny Hospital System restoring for the time being the affiliation agreement between health insurer Highmark and the hospital system. Back in August the hospital system walked away from the deal which had not yet closed (although Highmark had invested a lot of money in the facility.) The FEHBlog knows that the law establishes a high bar for obtaining this relief. The hospital system can appeal even though the case is not over.

Although it’s the FEHBlog’s job as a lawyer to belabor the obvious. the FEHBlog sees no reason in recounting yesterday’s election results. The upshot from the FEHBP’s perspective is that implementation of the Affordable Care Act continues full speed ahead. For the FEHBP, that means that Congress and their personal staff members will leave the FEHBP for the exchanges in 2014. Perhaps then the FEHBP will not be treated like a political football. (Query is that necessarily a bad thing.) The other change is that a plethora of ACA required taxes and fees will rain down the FEHBP necessarily leading to premium increases for 2014 above the low levels of the past two years.

Modern Healthcare compiled healthcare leader reactions to the election results here.

On Sunday, the FEHBlog noted a campaign to extend FEHBP coverage to first responders who work for FEMA as temporary employees. Earlier this year, OPM extended FEHBP coverage to first responders who work for the Forest Service as temporary employees and in the interim final rule implementing that change OPM solicited public input about adding other groups of first responders. Thus it did not come as much of a surprise to me when a colleague pointed out the following entry on reginfo.gov :

The FEHBlog ran across press releases about Humana’s acquisitions of Metropolitan Health Networks, a southern Florida company that owns 35 medical centers, and Certify Data Systems, a healthcare technology systems vendors to hospitals and other health care providers. These acquisitions are further examples of how health insurers are branching out into other related businesses where the government has not capped profits.

Finally, because the FEHBlog has been interested in the Walgreen’s / Express Scripts saga, here is a link to a story from Investor Plan that brings you up to date. (Spoiler alert: CVS came out on top.)  The article notes that Walgreen’s recently has dipped its toe back into the prescription benefit manager business by acquiring an interest in a  United Kingdom based PBM called Alliance Boots.

Well this is election week (finally). Next Monday, November 12, Congress will return to Washington and the Federal Benefits Open Season will begin. Here’s the link to OPM’s Open Season resources. Fedsmith.com announced that OPM again will be offering a series of Open Season how to webinars that begin on Tuesday November 6.

Earlier this years, President Obama ordered OPM to admit seasonal firefighters into the FEHBP. Typically seasonal employees are not eligible for FEHBP coverage. OPM complied with the President’s order in the summer and at this point these seasonal workers no longer are working for the Interior Department and are no longer receiving FEHBP coverage with a government contribution. Instead they generally must pay for temporary continuation of coverage until they are called to duty again. The FEHBlog brings this up now because the Washington Post reports that the folks who are temporarily working for FEMA to assist victims of Superstorm Sandy are complaining that they should receive FEHBP coverage. In the regulation extending coverage to the seasonal firefighter, OPM left the door open for extending FEHBP coverage to other temporary first responders. According to the Post article there are about 9,000 temporary first responders working for FEMA.

The federal government employs a lot of temporary employes who are not first responders but rather work for the IRS. Presumably this problem will resolve itself once the state health insurance exchanges are established.  It’s not clear to the FEHBlog whether the Affordable Care Act will require a large employer like the federal government to pay for health insurance for temporary employees who work more than 30 hours per week.  There has been a lot written lately about the fact that the pay or play provisions of the Affordable Care Act are limited to full time employees (30 or more hours per week).   It probably will be a case by case situation for the temporary employees.

Reuters reports that the American Hospital Association and others have sued the Health and Human Services Department challenging the way in which the Recovery Audit Contractor program is being administered.  Under the RAC program, private contractors working for HHS audit health care providers that bill Medicare and Medicaid (not the FEHBP) to identify overpayments by those programs. (FEHB plans undergo a variety of independent audits as well as audits conducted by OPM’s Office of Inspector General.)  “The RAC audit program, established under the Bush administration to curtail improper Medicare payments, has collected $1.86 billion in overpayments from October 2009 to March 2012, according to the court filing.”

The Wall Street Journal explains that the nub of the lawsuit is that when a RAC contractor concludes that inpatient care should have been provided on an outpatient basis, the hospital must refund Medicare’s payments (the RAC contractor receives a percentage of the recoveries), and Medicare refuses to cover the outpatient costs. The suit asks the court to order HHS to reimburse the hospitals for the patient’s care as if it were rendered on an outpatient bases.  

Following up on last Sunday’s New York Times article, the Pittsburgh Post Gazette printed an article about the multi-state plans that will be offered in the state health insurance exchanges based on OPM contracts, similar to the FEHBP. The reporter observes that

Traditional insurers * * * would seem to have little incentive to assemble and sell a multistate plan when they can sell products in the exchanges directly.

“Many questions remain unanswered because the federal government has yet to issue the request for proposal that will outline the requirements” of the multistate plans, said Janice Maszle, spokeswoman for Highmark Inc., Pennsylvania’s largest health insurer. “We do feel strongly that these plans must operate on a level playing field with the other qualified health plans on the exchanges, [which] will prevent adverse selection.”

The Federal Times reports that “While insurers report a growing willingness of federal [employee health benefit plan] enrollees to tap into their systems to make use of their medical information, the size of the growth is mixed. It’s still small for most carriers, with the large majority of their federal membership still balking at using the health records system, even though electronic records advocates insist they offer widespread benefits to users.”  The article does not mention that OPM’s most recent initiative has been to require FEHB plans to offer their members “blue button” access to their electronic records. The Blue Button permits plan claim records to be readily imported into a personal health records program like Microsoft Healthvault or a spreadsheet. The FEHBlog thinks that this technology will be more useful when offered by a healthcare provider because the providers records directly deal with the member’s health — as opposed to payment for the member’s health care. But experts have noted that while the medical community is getting accustomed to their brand new medical record systems, people sometimes need to fall back on their health insurance records, particularly in a pinch like “Superstorm” Sandy.

The FEHBlog has noted that the HHS Office for Civil Rights has been routinely slapping health care providers with $1.5 million fines under HIPAA when large volumes of electronic protected health information has been stolen. (Health plans are subject to these penalties as well but recently health care providers have been in the OCR bullseye.)  The FEHBlog took note of an U.S. Justice Department press release about a settlement with a check cashing company that failed to properly dispose of paper records containing confidential personal financial information subject to protection under the analogous Gramm-Leach-Bliley Act.

“A company that operates payday loan and check cashing stores in at least nine states has settled with the government over allegations that it violated federal regulations, the Justice Department announced today.   In April 2010, law enforcement officers retrieved boxes of intact consumer documents, including credit reports, from trash cans and dumpsters near four PLS Financial Services stores in the Chicago area.   The improper disposal of these documents led to an investigation by the Federal Trade Commission (FTC).  “

The company accepted a $101,500 fine. It’s good advertising for shredding companies and a reminder to HIPAA covered entities including health plans about the need to shred documents containing personal health information. .

Happy Halloween!  As we inch ever closer to the beginning of Open Season on November 12, OPM announced today that it has reactivated its Federal Benefits Facebook page (which the FEHBlog likes) and its Twitter feed (which the FEHBlog follows).

The Federal Times offered its first Open Season article yesterday on the topic of whether a low premium FEHB plan may be the right choice.

Following up on the Weekend post about health care costs, the FEHBlog noticed that AHIP is now offering an Ipad app called “U.S. Health Care Spending 101,” that “provides policymakers and stakeholders
with comprehensive health care spending data in an easy-to-use digital
format.”

As you know from reading the FEHBlog, the FEHBlog’s money is on personalized medicine bringing down the cost curve. The Wall Street Journal has an article aibout the progress being made in that area.

The AMA News claims that there’s a new trend toward domestic medical tourism, but the upshot is that many large employer health plans are refocusing attention on centers of excellence for certain high cost procedures like transplants. This good idea is nothing new. You will find that most FEHB plans particularly the nationwide plans offer centers of excellence arrangements.

Yesterday’s Washington Post had an article about domestic medical tourism from an uninsured individual’s standpoint. Hip replacement surgery overseas or in Oklahoma City?

OPM has required for the past two years that FEHB plan offer comprehensive tobacco cessation program with no enrollee cost sharing. Forbes Magazine reports that “Four new studies offer powerful evidence of the dangers of smoking and the health benefits of quitting or not being exposed to secondhand smoke.”

As the FEHBlog has mentioned, November 12 also will feature the return of Congress for its lame duck session. One must pass measure is legislation postponing the Medicare Part B’s sustainable rate of growth formula driven cut in Medicare payments to doctors or in the AMA’s dreams repeal and replacement of the SRG formula. The AMA News this week lays out the medical community’s repeal and replace strategy. Time will tell.

Batten down the hatches!!  Just two weeks from tomorrow, Congress will return for its post-election lame duck session and the Federal Benefits Open Season will begin.

Govexec.com recently undertook an unscientific survey of federal employee attitudes towards our beloved Federal Employees Health Benefits Program. Govexec.com reports today that “More than 90 percent of respondents to an October Government Executive poll characterized their FEHBP coverage as “good” or “satisfactory.” The question received more than 1,200 responses.” Here’s an interesting tidbit from the report

Another long-standing complaint from enrollees, and one that several Government Executive readers mentioned, was the lack of a self-plus-one option. FEHBP offers self-only and family coverage; those enrollees with spouses and no dependents must choose the family plan if they want coverage extended to their spouse. Some enrollees have balked at having to pay more for the family plan when they don’t have children, but Francis said a self-plus-one option would not be cheaper for enrollees. “If they got their wish, they would pay higher premiums,” Francis said, because that demographic consists largely of older, empty-nesters, who are more expensive to insure than a young couple with children. “OPM actuaries have confirmed that over and over,” Francis said.

The FEHBlog has heard the same opinion from OPM’s actuaries.  Although it’s not an apples to apples comparison, the premiums in the FEDVIP program which does allow for a self and one option logically step up from self only to self and one to self and family at the top. Of course, the FEDVIP law allows for the self and one option while the older FEHBP law does not. Conngress would have to change the FEHB law in order to create a self and one option.

OPM has unveiled its 2013 Federal Benefits Open Season webpage. The site includes a link to another webpage full of Open Season resources for the FEHBP, FEDVIP, and FSAFeds.  The Federal Daily staff also offered its thoughts on preparing for Open Season.

Modern Physician.com reports that “Without hesitation, Dr. Allan Korn, the Blue Cross and Blue Shield
Association’s chief medical officer and senior vice president for
clinical affairs, declared that the patient-centered medical home has
the potential to transform the U.S. healthcare system.”  The article quotes Dr. Korn as remarking that the Blues plans no longer can be considered to be piloting PCMH’s because 5.3 members (about 5% of all members) participate in the programs which focus on primary care and are intended to better coordinate all medical care.

The FEHBlog has noted that concerns have been raised in the press that hospitals may be using their government funded electronic healthcare technology to boost Medicare reimbursements. Modern Healthcare reports that “Hospitals using electronic health records have until Friday to complete a [54 question long] survey from HHS’ inspector general’s office asking myriad questions about how they use their EHR systems—questions that come at a time when critics have accused the industry of using the programs to increase revenue.”

Speaking of health care costs, last week, Standard and Poors released its August 2012 healthcare cost index report.

The average per capita cost of healthcare services covered by commercial insurance and Medicare programs increased by 5.70% over the 12-months ending August 2012. This is a deceleration from the +6.15% annual growth rate recorded in July 2012.

As measured by the S&P Healthcare Economic Commercial Index, healthcare costs covered by commercial insurance plans increased by 7.81% over the year ending August 2012, down from the +8.36% reported for July 2012. Annual growth rates in Medicare claim costs rose by 2.48%, according to the S&P Healthcare Economic Medicare Index, down from the +2.79% recorded in July 2012. The Professional Services Index annual growth rate was +6.67% in August 2012, down from the +6.95% July 2012 print. The Hospital Index’s growth rate fell to +4.54% in August from +5.11% recorded in July 2012.

It’s now just three weeks until Congress returns from the campaign trail and the Federal Benefits Open Season begins on November 12.

The AMA News recently has featured valuable articles providing the medical professions viewpoint on two Affordable Care Act creations — the Patient Centered Comparative Research Institute and the controversial Medicare Independent Payment Advisory Board.   The PCORI article raises the concern that comparative research studies even if conclusive do not necessarily change actual medical practices. In an effort to address this problem, the law funnels 20% of the PCORI funding fees contributed by insurers for publicity of findings through a HHS agency. The IPAB provides a vehicle for cutting Medicare funding of doctors services and prescription drug services (not hospital services until 2020). You can imagine how the AMA feels about that.

Kaiser Health News offered a report on the difficulty that people can encounter in trying to find coverage for certain eating disorders such as binge eating. According to the report,  “insurers say that experts have not identified clear protocols for
treatment. They note that there is little research on how best to treat
the mental and the physical aspects of an eating disorder.” Perhaps this is where the PCORI may fit in. In any event, here’s the rub:

To be sure, such disputes are not limited to eating disorders. With
rising health care bills, insurers have demanded more rigorous evidence
of the effectiveness of many treatments and pushed patients to cover a
greater share of their medical costs across the board. Patients, in
turn, have mounted consumer campaigns to pressure insurers and even
turned to lawmakers and regulators to force insurers to cover a variety
of diagnosis. For instance, strong parent advocacy efforts led 31 states to mandate coverage for autism, despite insurers’ concerns about the cost.

In the latest call letter, OPM approved FEHB plan coverage for applied behavioral analysis to treat autism. Previously, OPM had classified that therapy as a non-covered educational service. The advocacy group Autism Speaks reports that 38 FEHB plans will cover ABA therapy in 2013.