It’s so much easier to find FEHBlog worthy material when Congress is in session. There’s still a few more weeks until November 15 when the lame duck session starts. Of course, the Congressional election is Tuesday. Healthcare IT News reports on a speech by AHIP President Karen Ignani to the Nashville Healthcare Leadership Council. Her speech emphasized the importance of quality, productivity, and cost to successful healthcare reform. 

In [Ms Ignani’s] view, it’s futile to worry about the political identity of the next Congress.

“We need all stakeholders to get out of their comfort zone and participate in finding solutions,” Ignagni said. “Healthcare costs are still crushing the country. We have to go beyond the mindset of ‘my cost containment is somebody else’s revenue deprivation.’

Amen to that.

Meanwhile, Leavitt Partners, which is headed by the former HHS Secretary and former Utah Governor Mike Leavitt, is making predictions about how the new and as yet unelected Congress might change the Affordable Care Act according to this Hill article. The Leavitt firm describes their predictions as healthcare reform bracketology.

Health Leaders Media is reporting that the final HHS rules implementing the HITECH Act, which were proposed this past summer, are likely to be finalized by the end of this year or early next year. This includes the unsecured protected health information breach notification rule and the business associate rule.

AIS published a useful report on the difficulties that insurers are facing in applying the new preventive care guidelines applicable to non-grandfathered plans (effective 2011 for non-grandfathered FEHB plans). Non-grandfathered plans must provide certain in-network preventive care services with no cost sharing. The government regulations identify those services by reference to treatment guidance to providers which doesn’t necessarily translate to claims payment rules. Hopefully, the regulators will straighten this problem out over time.

The Wall Street Journal reported  on the problems that outpatient surgery patients face in managing their own rehabilitation process.

Surgery is easier and faster than ever before: Nearly 65% of all surgeries don’t require an overnight hospital stay, compared to 16% in 1980. Hospitals that once kept patients for three weeks after some major operations now discharge them within a matter of days. But the body still heals at its own pace, and reduced time in hospital care means patients are assuming more responsibility for their own recovery—and more risks.

Patients not only have to perform rehabilitation regimens at home, but they are more often caring for their own incision wounds and dressings and having to watch for signs of infections and blood clots. They also may be managing drains, implanted IV ports and pumps, all of which can be difficult and stressful.

The move to speedier surgeries is largely the result of new minimally invasive techniques, improvements in anesthesia and cost-cutting by insurance companies and hospitals. Surgical procedures now often use smaller incisions, cut less muscle, and result in less blood loss. Newer anesthetics allow patients to regain consciousness quickly or not go to sleep at all. Pain medications are more effective.

At the same time, concern about rising health care costs has led to changes in Medicare and insurance plans that have encouraged the development of outpatient surgical centers and created financial incentives for hospitals to shift less complex surgery to their own outpatient facilities. So, many types of surgeries previously performed in hospitals with overnight stays are now being done on an outpatient basis: The number of freestanding surgery centers grew from about 240 in 1983 to more than 5,000 now.

Business Insurance reports that ‘Walgreen Co., the largest U.S. drug- store chain, is looking to sell its pharmacy-benefits management business [which is the ninth largest in the U.S.] and has hired an adviser to run an auction, said three people with knowledge of the matter.”

The AMA News offers a report on the medical community’s perspective on “‘physician payment reform'” [which the AMA News describes as] “a catch phrase that refers to paying physicians based on quality measures and episodes of care, rather than a fee-for-service system.”

This AMA News article discusses the “National Committee on Quality Assurance’s annual State of Health Care Quality report. The 162-page report [available here], which looked at claims data from more than 1,000 health plans representing 118 million Americans, declared that spending more money on health care did not automatically lead to better health.”   Actually, the NCQA press release explains

Health plans that spend the most on care don’t always deliver the best quality

News that high-spending health plans don’t always deliver the best care comes from findings on relative resource use (RRU) – documented for the first time in the report across five common, costly and chronic diseases.

RRU indicates how intensively health plans use health care resources (such as physician visits and hospital stays), compared with other plans in the same region, serving similar members. When used alongside quality measures, RRU makes it possible to talk about quality and cost simultaneously.

Given the definition of value as the intersection of health plans’ spending (resource use) and their results, RRU reveals the value that plans offer.

RRU analysis shows that many plans that deliver below-average quality use above-average levels of resources. More care is not always linked to better results, confirming that the saying “you get what you pay for” does not apply to health care.

Last week, HealthGrades issued its 13th annual report on U.S. hospital quality.  The report finds a large quality gap between the hospitals awarded five stars by HealthGrades versus the hospitals awarded one HealthGrades star. This blurb from the press release caught the FEHBlog’s attention: “On average, one in nine patients developed a hospital-acquired complication, across the nine procedures evaluated for inhospital complications, from 2007 to 2009.”

The Affordable Care Act will require health plans, including FEHB plans, to provide enrollees with a four page standard benefit summary beginning in 2013. This four pager will supplement the FEHB plan brochure or the ERISA summary plan description. The National Association of Insurance Commissioners (NAIC) is responsible for providing the HHS Secretary with a template. The Politico offers a report on the NAIC’s work. According to the article, the NAIC is aiming to send its template to HHS in November.

The National Association of Insurance Commissioners approved a draft minimum medical loss ratio regulation today and sent it along to the Health and Human Services secretary for her consideration. The Secretary issued a press release thanking the NAIC and promising to issue the actual regulation soon. Forbes reports on the adverse impact that the rule is expected to have on HMOs and insurance brokers. The Forbes reporter writes

One person I spoke to recently, Evan Falchuk at Best Doctors, pointed out that the MLR caps take away the incentive for HMOs to keep costs down. Under the current rules if you are adept at either containing costs or pricing well, your MLR falls and it translates into profitability. With government-mandated MLRs, and forced rebates to consumers if you push the MLR down too far, what will be the incentive to keep costs in check?

AHIP expresses concern about the MLR reg here. It’s very unlikely in the FEHBlog’s view that HHS will make changes to this rule that favor HMOs.

The FEHBlog does not expect the rule to have an adverse impact on insured fee for service FEHB plans as explained briefly in Tuesday’s Tidbits. The MLR rule does not apply to self funded fee for service FEHB plans.

Fierce Healthcare reports that “Hospitals need to be on the hook for “higher leverage” safety measures if the Department of Health and Human Services’ wants its Hospital Compare website to ever be taken seriously. At present, the site–created to help patients pick the best facility for them based on various hospital statistics–is proving unhelpful for Medicare patients who need risky surgeries, according to a report published this week in the Archives of Surgery.”

CNN Money reports on the ongoing National Association of Insurance Commissioners meeting which is finalizing guidance to the Health and Human Services Secretary on implementation of the minimum medical loss ratio provisions of the Affordable Care Act. In the FEHBlog’s view, FEHB Program fee for service plans will have no problem satisfying the law’s 85% minimum loss ratio requirement for large group health plans. In any event, the ratio calculation and any resulting rebate will occur at the state level according to the guidance under consideration. The Politico Pulse is attending the conference and provides updates each morning. Once the NAIC finalizes its guidance, the HHS Secretary will prepare an interim final regulation.

The Federal Times reports about the federal government’s new anti-trust lawsuit filed against non-profit health insurer Blue Cross of Michigan. The lawsuit challenges the health insurer’s practice of negotiating so-called most favored nation pricing clauses in its hospital contracts. Blue Cross stated in a press release that 

Negotiated hospital discounts are a tool that Blue Cross uses to protect the affordability of health insurance for millions of Michiganders,” said Andrew Hetzel, BCBSM vice president for corporate communications. “Through this lawsuit, the federal government seeks to deny millions of Michigan residents the lowest cost possible when they visit the hospital.”

The American Medical Association has been pushing for this type of action.

Finally the FEHBlog wants to call to your attention the fact that OPM has refreshed its Federal Employees Group Life Insurance Program website. 

Last week, the Justice Department noticed an appeal from the recent Massachusetts federal district court decisions holding the Defense of Marriage Act unconstitutional. The Defense of Marriage Act currently prohibits coverage of same sex spouses under the Federal Employees Health Benefits Program. The Obama Administration wants Congress to enact the Domestic Partnership Benefits and Obligations Act, which will provide full benefits to same-sex partners of federal workers. The district court has stayed enforcement of its decisions pending the outcome of the appellate process. Unless the Court of Appeals accelerates the process, an appellate decision likely will be issued next year, following the upcoming federal benefits open season.

The Segal Company, a benefits consulting firm, issued its 2011 health plan trend cost survey. According to the press release, “[t]he report also discusses strategies for managing health care costs and notes that plan sponsors will need to address new rules and requirements as mandated under the Affordable Care Act. A brief summary of how plans are responding to certain provisions of the Affordable Care Act is provided.”

The Wall Street Journal reports on renewed health insurer efforts to control medical costs through wellness programs and devices such as medical homes, accountable care organizations that team up hospitals and doctors. Insurers have been at this for a while but the poor economy and the Affordable Care Act upheaval may create leverage with health care providers

NPR reports on insurers offering “high performance” provider networks to employers.  “They come in a few different flavors:

• Doctors or hospitals may be placed into different tiers based on the insurer’s evaluation of their cost and quality. You may have a lower copayment and deductible if you use one of the providers in the first tier that is deemed most efficient.
• Some providers in a health plan may be designated as the high-performance group, and you may get a lower premium if you choose them as your network.”

The Affordable Care Act requires employers, including the U.S. Government, to report the cost of employee health insurance on the annual W-2 form as a way to make that cost more visible to employees. The Internal Revenue Service released a draft 2011 W-2 form today — the form that will be used in January 2012 — and announced that the IRS will not enforce this requirement until the 2012 reporting year — the W-2 that will be distributed in January 2013.

The Labor Department issued two more FAQs on Affordable Care Act implementation, neither of which applies to the FEHBP.

AHIP has launched a Spotlight on Community Leadership, an online showcase of the innovative efforts of AHIP Member Organizations to improve the health and well-being of those in their communities through special outreach and service programs.

The Wall Street Journal reports that an increasing number of people are declining to pick up or purchase their filled prescription at the pharmacy. The Journal compared records from the second quarter of this year to records from 2006 before the Great Recession. However, the FEHBlog has noticed that its pharmacy has begun to refill prescriptions without being asked. That’s another change from 2006. So is it possible that the customer does not know that the prescription needs to be picked up. The Journal also reported on a new program by prescription benefit manager Express Scripts “that aims to contact people who fail to take their prescription drugs—before they actually stop.”

On Friday, the Labor Department issued a set of new frequently asked questions about the regulations implementing the Affordable Care Act’s insurance market reform provisions. Most of the guidance concerns the circumstances under which a group health plan loses grandfathered status. That’s not a continuing issue for most FEHB plans because the initial regulatory guidance came out after the 2011 benefit and rate proposals had been submitted to OPM. The Q&A on rescissions confirmed the anti-rescission provision’s broad scope, while the Q&A on preventive health services provided useful guidance to FEHB plans.

The National Healthcare Anti-fraud Association, an excellent organization to which many FEHB plan carriers and the OPM Inspector General’s office belong, issued a white paper on combating health care fraud in the post-health care reform world. The organization’s press release explains “Health care fraud is both a multi-billion-dollar crime and an endangerment to public health. NHCAA’s white paper concludes that the fight against health care fraud will be enhanced if measures such as increased sharing of anti-fraud information, stronger auditing procedures and greater investment in fraud-fighting programs are adopted.”

Govexec.com reports on premium increases in the federal employee dental and vision insurance program (FEDVIP) for 2011.

The FEHBlog is hopeful that unlocking the human genome will lead to new, more effective treatments that over time will reduce health care costs. The Wall Street Journal posted an article by author Matt Ridley who writes on genomics and takes the opposite viewpoint. Mr. Ridley’s latest book is the Rational Optimist.

OPM today issued its annual benefits administration letter identifying significant changes to the FEHB Program for 2011. There are two new HMOs joining the Program for 2011 and there are a number of HMOs that are either leaving the Program or modifying their service areas. Employees currently enrolled in plans that will be unavailable in 2011 must re-enroll in the upcoming Open Season for a replacement plan.

Dear FEHBlog readers, the FEHBlog apologize that the chart that I posted last night did not fit on the blog page. It looked OK in the composition box. Fortunately, I discovered the mistake earlier today, and it’s fixed now.

In the fact sheet that OPM posted about 2011 FEHB premiums on October 1, the agency remarked

OPM will soon launch a new Health Claims Data Warehouse which will become a useful tool for analyzing health services data from the FEHB plans. The warehouse will allow OPM to better understand the health of federal employees, as well as the cost and quality of care they receive. The warehouse will give OPM the ability to manage the program so that employees and tax-payers get the best value.

Today, OPM published in the Federal Register a Privacy Act system of records notice about the health claims data warehouse. Govexec.com reports that this notice has raised concerns with privacy advocates.

The Labor Department has posted on its Affordable Care Act website links to the public comments which were filed about the interim final rule implementing the Affordable Care Act’s preventive care mandate (applicable to non-grandfathered plans) and the Act’s internal claim and appeal mandate .  This mandate will be treated as the new internal claim and appeal standard for the FEHB Program in 2011.  The OPM external appeal process created by the FEHB Act and OPM regulations is unaffected by the Affordable Care Act.