Two major OPM initiatives are requiring fee-for-service FEHB plans to adopt certain HEDIS quality measures and to provide price and quality transparency. The American Medical Association voted at its annual meeting this week to adopt these related policies:

“Patient adherence to treatment plans: The AMA voted to recognize that patient adherence to any medical treatment program is necessary in order to achieve high quality and cost-effective health care, and agreed to develop a list of resources to help physicians and patients optimize adherence. “‘For any health or wellness program to succeed, we must find ways to help patients follow through on treatment plans,” said AMA President-elect Ronald M. Davis, MD. “The best health outcomes occur when the physician and patient work together toward a common goal.'””Health plan and insurer transparency: In support of consumer-directed health care and an end to the mystery of medical prices, the American Medical Association (AMA) today called on the health insurance industry to end efforts to conceal their pricing systems for medical services. “Physicians at the AMA Annual Meeting agreed that patients need price transparency from all sectors of the health care system, but noted that pricing is largely outside of physicians’ control. It is based on a complex array of factors that are controlled by health insurers and often imposed upon physicians. [Blog note — That’s rich. Health benefits are a more a price support for doctors than an insurance product — will you be upset if you don’t get a home owners insurance claim payment this year — no, because that’s real insurance covering a risk that you don’t want to materialize. ]
“AMA pledged to take actions that would promote true price transparency, including calling on health plans to make their payment policies, claims edits, benefit plan provisions and fee schedules available for public viewing.”As I have said on the blog in the past, doctors have to bury the hatchet with health plans and work cooperatively to control health care costs. Improving patient compliance with doctor directions is a step in the right direction but refusing to recognize their role in the price setting process is a step back.

Both the House Energy and Commerce Committee (28-14) and the House Ways and Means Committee (23-17) reported out their respective versions of H.R. 4157, a health information technology promotion law. There are several difference between the two bills, the most significant of which from a health plan prospective is that the Ways and Means bill mandates implementation of the ICD-10 coding system in 2009 while the Energy and Commerce bill does not. The House leadership now will have to reconcile the two bills if they want to have a productive Health Week.

The U.S. Supreme Court ruled today that federal courts do not have jurisdiction over an FEHB carrier’s lawsuit to enforce its subrogation/reimbursement rights against an FEHB plan member. Empire Healthchoice Assurance, Inc. v. McVeigh, — U.S. — , No. 05-200 (PDF copy), affirming the Second Circuit’s opinion. According to the majority opinion, written by Justice Ruth Bader Ginsburg, in this 5-4 decision, “Federal courts should await a clear signal from Congress before treating” these recovery cases as arising under federal law for purposes of federal court jurisdiction under 28 U.S.C. § 1331 (Slip op, p. 2). Justice Breyer, supported by Justices Kennedy, Souter, and Alito, wrote a strong dissent that makes perfect sense to me.

The Supreme Court soon will grant certiorari and remand the related Cruz case (No. 04-1657) back to the Seventh Circuit for reconsideration in light of McVeigh.

This is the first time that the Supreme Court has issued an opinion interpreting the FEHB Act, a statute that the Wall Street Journal’s Law Blog described as “relatively obscure.” (What does that say about my blog??)

The Institute for Health Care Improvement sponsors the 100,000 Lives Campaign to improve hospital care by implementing up to six evidence-based and life-saving interventions at participating hospitals. The Institute reported today that over the first 18 months of this program has avoided an estimated 122,300 deaths at 3,000 participating U.S. hospitals. What’s more,

As a result of the Campaign, many patients have begun to enjoy a new standard of care. Over 20 facilities have reported that they have gone over a year without a Ventilator-Associated Pneumonia, a leading killer among all hospital-acquired infections, demonstrating that this sort of complication can be avoided and is not inevitable. Hundreds of hospitals have also now instituted rapid response teams, a relatively new concept that is saving lives. Participating hospitals have also made great headway in delivering reliable care for Acute Myocardial Infarction, preventing adverse drug events, and preventing surgical site and central line infections.

Now that’s the Hippocratic Oath in action!

The House of Representatives reportedly is planning to hold a health week beginning June 20. The marquee attraction may be H.R. 4157, the Health Information Technology Improvement Act of 2006. As noted in a prior entry, the Ways and Means Committee’s health subcommittee reported out a version of the bill that mandated health plans to implement the new ANSI 5010 837 standard electronic claim in March 2009 and the ICD-10 diagnosis and inpatient procedure coding system in September 2009. (The full Committee has not scheduled a markup of this bill yet.)

AHIP urged Congress to delay ICD-10 implementation until 2012. On June 8, the Energy and Commerce Committee’s health subcommittee reported out a different version of HR 4157, titled the Better Health Information System Act that does not include the ICD-10 mandate, among other differences between the two bills. (A victory for common sense.) The full Energy and Commerce Committee plans to mark up this bill tomorrow morning. It appears that the Energy and Commerce version of the bill has the big mo. (Meanwhile the medical community continues to question the financial and time investments required for HIT implementation.)

The Senate already has passed a bipartisan health information technology bill, S. 1418.

On May 15, the initial open enrollment period for Medicare’s prescription drug program known as Medicare Part D ended. CMS reported a surge in enrollments before the open enrollment concluded. CMS also reported that the average Medicare Part D premium for 2006 is under $24 per month, significantly below the $36 benchmark price that CMS projected soon after the law was enacted.

Medicare Part D plans submitted their 2007 bids on June 5 (similar to FEHB plans which submitted their 2007 benefit and rate proposals on May 31). According to BNA, experts are predicting that 2007 Medicare Part D premiums will be 5% to 8% lower than 2006 premiums because the Medicare law provides for aggregate reinsurance to help Part D sponsors launch the new product. The thresholds for these “risk corridor” payments double in 2008 so plans may want to build enrollment in 2007. CMS is expected to announce the 2007 benchmark premium in August 2006.

On June 8, the Blue Cross and Blue Shield Association announced its new Blue Distinction program which, according to the Association, includes the following components:

• “Blue Distinction National Transparency Demonstration — A national transparency demonstration by 17 Blue Plans ensures that we are providing consumers with the most effective ways to learn about absolute and relative healthcare costs.
• Blue Distinction CentersSM — The Blue Distinction Centers identify quality providers of bariatric surgery, cardiac care and transplant services nationwide.
• Blue Distinction Provider Measurement and Improvement ProgramSM — The Blue Distinction Provider Measurement and Improvement Program integrates provider performance metrics from public sources into a national framework for improving healthcare quality.”

The Federal Workforce and Agency Organization subcommittee of the House Government Reform Committee held a second hearing today on H.R. 4859, the Federal Family Health Information Technology Act, which Chairman Jon Porter (R NV) and Rep. Lacey Clay (D MO) have sponsored. Chaiman Porter indicated that he plans to markup the bill soon.

Diabetes cases have been surging in the United States and around the world. Pfizer will begin marketing an inhalable form of insulin called Exubera in July 2006. The short acting treatment will not entirely replace insulin injections. Analysts have predicated a $1 billion market for this drug and insurers are expected to place it in the highest copayment tier according to the Wall Street Journal’s report (subscription wall).

Merck and Novartis meanwhile are reported close to FDA approval of a new class of drugs called a DPP-4 inhibitor to treat diabetes 2. (Diabetes 2 used to be called adult onset diabetes; except in severe cases it does not require insulin therapy. The name Diabetes 2 is now used because many younger people are contracting the disease due in part to to obesity problems. Diabetes 1 previously was called juvenile onset diabetes and always requires insulin therapy.) The DPP-4 inhibitors work to decrease blood sugar levels, rather than increase insulin production, the objective of current diabetes drugs.

Merck’s drug is called Januvia and FDA approval is anticipated in the fall. Novartis’s drug is called Galvus and FDA approval is expected next year. Both drugs could achieve annual sales over $1 billion according to the Wall Street Journal report.

What’s more, Japanese researchers have announced a possible breakthrough in Alzheimer’s Disease treatment — a gene based vaccine that has worked on mice without causing the brain swelling problem that a previous experimental vaccine caused. Next step – monkey tests and then humans.

The Veterans Affairs Department’s Secretary sent a letter to all veterans last week about the massive security breach caused by the theft of an employee’s laptop. An enclosure to the letter explains that the Department is taking the following remedial measures:

The Department of Veterans Affairs is working with the President’s Identity Theft Task Force, the Department of Justice and the Federal Trade Commission to investigate this data breach and to develop safeguards against similar incidents. The Department of Veterans Affairs has directed all VA employees to complete the “VA Cyber Security Awareness Training Course” and complete the separate “General Employee Privacy Awareness Course” by June 30, 2006. In addition, the Department of Veterans Affairs will immediately be conducting an inventory and review of all current positions requiring access to sensitive VA data and require all employees requiring access to sensitive VA data to undergo an updated National Agency Check and Inquiries (NACI) and/or a Minimum Background Investigation (MBI) depending on the level of access required by the responsibilities associated with their position. Appropriate law enforcement agencies, including the Federal Bureau of Investigation and the Inspector General of the Department of Veterans Affairs, have launched full-scale investigations into this matter.

More details on these remedial measures can be found in the testimony given before the House Government Reform Committee on June 8. Today’s Washington Post features an interesting article about the wider impact that this security breach is having on employees who work at home (telework).