Measles is a highly contagious, viral infection that can be dangerous to young children. (I suffered through the illness as a child, and it was not fun. The vaccine became available after I had the disease which creates immunity.) Measles was thought eradicated in the United States in 2000 due to a high effective and safe measles, mumps, and rubella vaccine. In 2005, 34 cases of measles occurred in an Indiana community, the largest outbreak in years.

The New England Journal of Medicine this week published a study on this outbreak written by Amy Parker and others. Mayoclinic.com summarizes the NEJM study’s findings as follows:

In 2005, an unvaccinated 17-year-old from Indiana traveled to Romania and unknowingly contracted the measles virus, according to a study in the New England Journal of Medicine. When she returned home, the virus quickly spread. Within six weeks, 34 cases of measles were confirmed — the largest documented measles outbreak in the United States since 1996. Most cases were among children and teenagers ages 5 to 19 who hadn’t been vaccinated. More than 70 percent of these children were home-schooled. The measles outbreak was mostly confined to children whose parents had not consented to vaccination, primarily due to concern about vaccine safety. Researchers concluded that high vaccination levels in the surrounding community and low rates of vaccine failure prevented an epidemic.

FEHB plans routinely cover childhood vaccinations, such as the MMR vaccine. ABC News notes

Why do some people choose not to vaccinate their kids? In 1998, the Lancet, a British medical journal, published an article that claimed that the MMR (measles-mumps-rubella) vaccine caused autism in children. The article has since been retracted, but the worry has remained.

That’s a shame. The NEJM study concludes that

The outbreak in Indiana shows that states, localities, and health care organizations need to implement more effective policies to protect persons traveling abroad, home-schooled children, and health care workers against measles and other vaccine-preventable diseases. In addition, to preclude the experience of those countries where vaccine-preventable diseases have become epidemic through the refusal of vaccination, better communication strategies are needed concerning the adverse events associated with vaccines. These efforts will be necessary to sustain the elimination of measles in the United States.

The Commonwealth Fund released the “Framework for a High Performance Health System for the United States” a report today prepared by an 18 member commission formed by the Fund. Not surprisingly the commission members find that

[A]lthough some of the best medical care in the world is delivered in the United States, when examined as a whole our country falls far short of providing high-quality, safe, well-coordinated, and efficient care, accessible to all Americans—and that we are failing to deliver adequate value for the very high proportion of resources we devote to health care in this country.The report * * * states that there are concrete steps that could be taken to improve value, for example:

• Implementing major known quality and safety improvements;
• expanding the use of information technology;
• rewarding performance for quality and efficiency through our payment systems;
• increasing public reporting on quality and costs; and
• importantly, expanding health insurance coverage.

The Commission finds that central to implementing these changes is the need to establish more organized systems of care so that individual practitioners and hospitals can have:

• A structure within which to implement known quality and safety improvements;
• a structure to invest in and support appropriate information technology advances;
• a sufficiently broad base to enter into pay-for-performance contracts which reward quality and efficiency;
• the ability to provide reliable and objective public comparison of results among systems and providers; and
• the ability to care for patients across a range of needs for acute and chronic services.

The subways were delayed today in DC today due to the heat which gave me an opportunity to read this week’s Business Insurance issue. I found an interesting point-counterpoint article on pill splitting. United Healthcare has been one of the most prominent insurers to encourage the practice. It turns out that for example Pfizer charges the same price for a 40 mg pill of the statin Lipitor as it does for a 20 mg pill of the same drug. So if the member on a 20 mg daily dose of the drug gets a 30 day supply of 40 mg pills, she can get two months of the medication for one co-pay.

“According to Tim Heady, chief executive officer of UnitedHealth Pharmaceutical Solutions, [United Healthcare’s] Half Tablet Program offers a potential savings of up to 1 to 2 percent of total drug spend, and members can save up to $300 annually.” Moreover, Stanford University researchers have concluded that the practice has significant potential for cost savings.

The [Stanford] researchers emphasized that pill-splitting must be implemented with drug-specific and patient-specific criteria to ensure patient safety. Just as certain types of medications are unsuitable for pill-splitting – including extended-release medications and those with enteric coatings – certain patients may be unable to split tablets consistently and accurately. Such patients may include those with poor eyesight, loss of a limb, tremors, debilitating arthritis, dementia or psychosis. The researchers noted that results are best when the patient uses a pill-splitting device and is trained to use it. Pill-splitting should be embarked upon only after a discussion between physician and patient, Stafford explained. “We’re not advocating this as a global solution. It needs to be conducted in the context of doctor-patient communication.” He noted that the list of 11 medications he identified for pill-splitting isn’t exhaustive and may differ depending on local practices and prices.

The American Medical Association similarly accepts voluntary pill splitting programs that require doctor input in the pill splitting decision. However, many members do not want to split pills (but if bakeries can slice bread that you purchase from them, why can’t pharmacists split the pills you buy from them ?)

Other insurers, such as Cigna Healthcare, prefer focusing member attention on using low cost generic drugs which are available in all the classes of drugs recommended for splitting, according to Business Insurance. What’s more the brand name manufacturer practice of charging the same price for several dosages is not as prevalent with generic drug manufacturers. Yet other insurers, such as Health Partners, include generic drugs in their pill splitting program.

U.S. Department of Health and Human Services (HHS) Secretary Michael Leavitt announced two final rules that will be published in the August 8, 2006, Federal Register. These rules are intended to foster the spread of health information technology.

The Centers for Medicare and Medicaid Services will be creating two exceptions from the physician self-referral prohibitition (Social Security Act § 1877) — one for donations of electronic prescribing (“e-prescribing”) equipment that meets Medicare Part D standards and the other for interoperable electronic health record (“EHR”) software. Recipient physicians must contribute at least 15% of the donor’s cost for the interoperable EHR software, but can accept the e-prescribing equipment for no charge, but subject to other prerequisites described in the rule.

The HHS Inspector General will be creating e-prescribing equipment and interoperable EHR software safe harbors from the federal health programs anti-kickback act (from which the Federal Employees Health Benefits Program is exempt.) These safe harbors like the physician self-referral law exceptions impose no limit on the value of e-prescribing equipment but require a 15% copay toward the value of EHR software.

According to HHS’s press release,

The scope of donors and recipients under the final rules is considerably broader than in the proposed rules. Donations protected under the exception may be made to any physician by entities furnishing DHS. The exception requires compliance with criteria similar to those listed in the electronic prescribing exception, as well as additional criteria, such as those requiring cost sharing and selection of physician recipients of donated technology. The corresponding OIG safe harbor is similar. However, consistent with underlying statutory differences, the safe harbor covers a broad array of providers, suppliers, practitioners and health plans when they provide electronic health records technology to physicians and others engaged in the delivery of health care.

These rules take effect sixty days after Federal Register publication. The self-referral law exception and safe harbor for EHR software donations will expire at the end of 2013. There is no corresponding sunset limitation on the exception and safe harbor for e-prescribing equipment.On a related note, CCHIT certified two new EHR products as interoperable yesterday.

On July 17, the FEHBlog noted Robert Pear’s article in the New York Times warning that the Centers for Medicare and Medicaid Services’ proposed Medicare diagnostic related group (DRG) reforms would whack Medicare reimbursements to hospitals by 20 to 30%. Modern Healthcare.com reports that CMS Administrator Mark McClellan stated at a press conference today that CMS now is planning to phase in the reforms over a three year period and that only 2% of hospitals would experience Medicare reimbursement reductions as a result of the reforms.

On Friday July 28, the Treasury Department and the Internal Revenue Service (IRS) issued final rules governing the required comparability of employer contributions to employees’ health savings accounts. The proposed rule was published in August 2005.

The Treaury Department’s press release explains that

Comparability rules provide that an employer contributing to one employee’s HSA must contribute comparable amounts to all employees who have HSAs. The final regulations expand the flexibility of the proposed rules issued in August 2005.In particular, the final regulations include the following features:

• An exception from the comparability requirement for groups of collectively bargained employees;
• The ability to make different comparable contributions based on different variations of family coverage;
• Further clarification of the exclusion from the comparability requirement for employer contributions made through a cafeteria plan.Generally, under the final rules if employees are allowed to contribute to an HSA by salary reduction through a cafeteria plan, all employer contributions to the employee’s HSA will be treated as being made through a cafeteria plan (and thus excluded from the comparability rules).

The new rules apply to employer contributions made on or after January 1, 2007.

The Wall Street Journal yesterday featured an article about the 83 year old philanthropist David Murdock who owns Dole Foods, among other companies. Mr. Murdock is building the California Wellbeing Institute outside Los Angeles. The Journal describes the Institute as ” a combination Four Seasons luxury resort, conference center and nutrition-counseling school.”

It was most interesting to me that the health insurer Wellpoint has assumed a 15% ownership interest in the Institute. The Jurnal article further explains that in 2004, “Mr. Murdock convinced [then Wellpoint CEO Leonard] Schaeffer that WellPoint should team up with him. Mr. Schaeffer saw wellness as a promising business area, with good boomer demographics and the potential to attract cash-paying customers, free from the constraints of medical insurance.” The Institute is scheduled to open in November 2006.

Last month, as noted in the FEHBlog, the House Ways and Means Committee and the House Energy and Commerce Committee passed their own versions of HR 4157, the Health Information Technology Improvement Act. Yesterday, the House Rules Committee passed a resolution (H. Res. 952) reconciling the two measures and permitting various amendments to be considered on the floor of the House. This afternoon, the House considered and passed the bill by a 270-138 vote. The White House issued a statement of support for the House bill.Of greatest importance to health plans, the House bill would require implementation of the ICD-10 diagnosis and inpatient procedure codes in October 2010 (rather than October 2009 as provided in the Ways and Means Committee report and October 2012 as urged by AHIP).

The House and the Senate now will hold a conference committee to reconcile HR 4157 and S. 1418 which the Senate passed last November.

Recently, I noted in the FEHBlog that the CVS pharmacy chain had purchased MinuteClinic, a much smaller chain of walk-in clinics staffed by nurse practitioners and physician’s assistants. Laura Landro reports in yesterday’s Wall Street Journal that CVS plans to incorporate MinuteClinics in 1000 of its pharmacies over the next three years.

Even more interestingly, Ms. Landro reports that regional healthcare systems such as Atlanticare in New Jersey are establishing their own walk-in clinics on a divide and conquer theory. The walk-in clinics will treat the mildly ill at low prices but feed the more seriously ill to the system’s doctor network.

In a similar arrangement, the TakeCare chain of walk-in clinics has arranged for support and cross-referrals from Advocate Health Partners in Chicagoland. She cites to several other examples.

According to Ms. Landro, Blue Cross and Blue Shield of Minnesota “which analyzed 22,956 visits by its members to MinuteClinics from June 2004 to June 2005, found the clinics cost about half an office visit — or $43 versus $87 — and less than half for other related costs such as lab services.”

The AMA News in its July 24/31 issue reports on a “pay for quality” pilot conducted by Healthspring‘s Medicare Advantage plan and the Sumner Medical Group, a 15 doctor group in Tennessee. (I was in Nashville this week and greatly enjoyed a Tuesday performance of the Grand Ole Opry.)

In this program, Healthspring retained Healthways, a local disease management company, to provide Sumner Medical with free nursing support to track patients with chronic illnesses between visits, among other services. Healthspring also offered the Sumner Group doctors a 20% pay bonus for hitting quality targets.

Sumner Medical informed the AMA News that the program resulted in an improvement in their patients’ health outcomes. The doctors appreciated that the health plan assumed the cost of the disease management nurses and did not impose a financial penalty on the doctors. The health plan enjoyed the medical underwriting gain from the program. Healthspring is planning to extend the program to 12 other markets. Other health plans are evaluating Healthspring’s model.