FEHBlog

The President released his approach to solving the surprise billing problem today. Principally

The Administration wants to ensure patients are not price gouged in emergency situations by out-of-network providers they could not choose. In emergency situations, balance billing for amounts above the in-network allowed amount should be prohibited. 

The Administration wants to bring transparency to the confusing and opaque pricing system patients face when scheduling care.  Before scheduling their care, patients should be given information about whether the care providers are out of their network and what related costs that may bring.

The FEHBlog’s preferred approach to emergency care is having each hospital require their affiliated providers to participate in the same networks in which the hospital participates.

Beckers Hospital Review reports that UniedHeathcare has rolled out a new bundled maternity care package.

The bundled payment program, launched with two healthcare providers in New Jersey and Texas, will reimburse care providers or a hospital for an episode of care — including prenatal, delivery and postpartum services — under a single payment. The bundled payments will link provider reimbursement to care outcomes.  The program, developed in partnership with healthcare provider organization U.S. Women’s Health Alliance, is slated to encompass up to 20 provider groups by the end of the year.

 Smart move.

The Senate Health Education Labor and Pensions Committee held a hearing on the 21st Century Cures Act on Tuesday.  Healthcare Dive provides a report on the hearing which considered the proposed HHS interoperability rule. The FEHBlog thinks that there good ideas in these rules which will help implement the President’s second no surprises principle stated above. However, HHS proposes to implement these technology driven changes way too fast, to wit, January 1, 2020. The Committee Chairman agrees:

“My major concern is to remind the administration of the advice that my piano teacher used to give me before a recital,” committee chairman Lamar Alexander, R-Tenn., said. “She’d say, ‘Lamar, play it a little slower than you can play it. You’re less likely to make a mistake.'”

Well put, Mr. Chairman. Also don’t bite off more than you can chew.

Modern Healthcare reports on a recent RAND study finding that employer sponsored health plans pay hospitals 241% more than Medicare for the same services.

“If you ask hospitals, they will pretty commonly say that ‘our prices are high because we lose money on Medicaid patients and barely break even on Medicare.’ But if you kind of look at the data, that story doesn’t hold up that well empirically,” said Christopher Whaley, one of the study’s authors. “Sometimes hospitals that can charge higher prices because of market clout, reputation or must-have status do so.” 

[Affordable Care Act driven] Consolidation among hospitals across the nation has helped boost their ability to negotiate higher prices from health plans, studies have shown. If employers and health plans participating in the study paid hospitals Medicare rates, they would have paid $7 billion, or about 50%, less over the study period, researchers concluded. 

AIS Health provides a useful article on the annual drug trend reports (including links) for three large prescription benefit managers — CVS Health / Caremark, Express Scripts and Prime Therapeutics. Check it out.

Fierce Healthcare reports that

Kaiser Permanente plans to roll out a new care network to more effectively connect its 12.3 million patients to the community services they need, such as housing, food, or transportation.

The health system is partnering with Unite Us, a social determinants technology and care coordination platform, to build the technology infrastructure that will enable Kaiser Permanente to better address social determinants and  “connect all the dots in a systematic way” for its millions of members, Kaiser Chairman and CEO Bernard Tyson told FierceHealthcare.

The initiative aims to equip all of Kaiser Permanente’s healthcare providers with technology tools to better address patients’ social determinants of health. The health system plans to start rolling out the network regionally this summer. The goal is to make the network available across its entire system within three years to serve the 68 million people in the communities it serves.

Bravo.

The Department of Health and Human Services finalized a federal rule today generally requiring prescription drug manufacturers to post prices in the consumer advertising shown on television. The accompanying fact sheet explains

• The rule will require direct-to-consumer television advertisements for prescription drug and biological products covered by Medicare or Medicaid to include the list price – the Wholesale Acquisition Cost – if that price is equal to or greater than $35 for a month’s supply or the usual course of therapy, with the prices updated quarterly.
• The 10 most commonly advertised drugs have list prices ranging from $488 to $16,938 per month or usual course of therapy. Patients deserve to know what a drug costs as they discuss their options with their doctor.
• The final rule will go into effect 60 days after it was published in the Federal Register.
• If a manufacturer simply includes price information in a direct-to-consumer advertisement as required by § 403.1202, that information in the advertisement will not require review by the FDA Office of Prescription Drug Promotion (ODPD). OPDP does not review price information in prescription drug advertisements and does not intend to do so in the future, unless the price information explicitly or implicitly incorporates safety or efficacy information about the drug, or makes express or implied claims about the safety or efficacy of the drug.

Sen. John Cornyn (R-Texas) offered specific examples of drugs that have benefited from system issues, including Humira, an expensive drug for arthritis and psoriasis that is protected by 136 patents.

That’s called a “patent thicket,” because it prevents a generic alternative from entering the market for more years — in this case, until 2023 for a drug first approved for use in the United States in 2002. “Is there anyone on the panel who’d like to defend the status quo?” he asked.

“There is no way a biosimilar can deal with a hundred patents,” testified Michael Carrier, a professor at Rutgers Law School. “This is an abuse of the system.”

Amen to that.

Celebrated New York Times health policy reporter Robert Pear died yesterday at age 69. Here is a link to his obituary in his newspaper.  RIP.

The Senate Homeland Security and Governmental Affairs Committee (“HSGAC”) held a confirmation hearing this afternoon for the President’s nominee for OPM Director, Dale Cabaniss.  FedScoop reports on the hearing here. The FEHBlog watched the hearing. It’s worth noting that Ms. Cabaniss, in contrast to the immediately preceding OPM Director Mr. Pon, is not interested in digitizing all of the personnel records in OPM’s Boyers PA cave.

Meritalk.com reports that the House Oversight and Reform Committee plans to grill the OPM Acting Director Margaret Weichert about the President’s plan to reorganize OPM on May 23. However, it is all together possible that on May 23 Dale Cabaniss will be the Senate confirmed OPM Director.  Time will tell.

The Chairman of the Senate HSGAC, Sen. Ron Johnson (R Wisc)  is taking another shot at repealing the Affordable Care Act provisions creating the OPM-mananged multi-state program, which currently has one participating single state plan in Arkansas.  According to the press release, OPM is one of the groups supporting repeal.

The Wall Street Journal reports that a new Novartis curative gene therapy drug Zolgensma is expected to be priced at $2 million per course of treatment.

Gene therapies target diseases that result from a faulty gene by introducing a working version into the body. They are attracting interest, both for their ability to cure otherwise devastating illnesses in one treatment and also for their high cost. Luxturna, the only gene therapy on sale in the U.S. so far to treat a form of inherited sight loss, costs $850,000 a patient. 

“A therapy is useless if no one can afford it,” said Cathryn Donaldson, a spokeswoman for America’s Health Insurance Plans, an industry association. She said members want to encourage innovation but that high prices are a problem.  The issue is gaining in importance as more gene therapies go on sale. The Food and Drug Administration expects to approve 10 to 20 gene and cell therapies a year by 2025.

The Centers for Disease Control issued a timely report on maternal deaths in the U.S. which is a topic in the 2020 OPM call letter for FEHB benefit and rate proposals.

In the merger and acquisitions world —

• Healthcare Dive reports on the status of Centene’s efforts to acquire Wellcare. 
• Healthcare Leaders reports on the upcoming court hearing on the CVS-Aetna merger. 

Happy Public Employee Recognition Week!

MobiHealth News reports that the National Institutes of Health celebrated the first anniversary of the All of Us public health res earch program, in which the FEHBlog participates, by unveiling its All of Us Research Hub. For more information on the All of Us program, click here.

The HHS Office for Civil Rights announced a $3 million HIPAA privacy and security rule violation settlement with Touchstone Medical Imaging.

In May 2014, Touchstone was notified by the Federal Bureau of Investigation (FBI) and OCR that one of its FTP servers allowed uncontrolled access to its patients’ protected health information (PHI).  This uncontrolled access permitted search engines to index the PHI of Touchstone’s patients, which remained visible on the Internet even after the server was taken offline. 

Touchstone initially claimed that no patient PHI was exposed.  However, during OCR’s investigation, Touchstone subsequently admitted that the PHI of more than 300,000 patients was exposed including names, birth dates, social security numbers, and addresses.  OCR’s investigation found that Touchstone did not thoroughly investigate the security incident until several months after notice of the breach from both the FBI and OCR.  Consequently, Touchstone’s notification to individuals affected by the breach was also untimely.  OCR’s investigation further found that Touchstone failed to conduct an accurate and thorough risk analysis of potential risks and vulnerabilities to the confidentiality, integrity, and availability of all of its electronic PHI (ePHI), and failed to have business associate agreements in place with its vendors, including their IT support vendor and a third-party data center provider as required by HIPAA.

The Wall Street Journal reports tonight that

As measles cases rose last week to a new high of 764 cases this year in 23 states, a battle is heating up in New York state over a proposal to tighten vaccination requirements for those attending schools. The new total is 60 cases more than a week ago, according to a weekly update from the Centers for Disease Control and Prevention. 

* * * 

Only three states—California, Mississippi and West Virginia—ban religious exemptions for immunization, according to the National Conference of State Legislatures. Legislators in several states have pushed in recent months to remove parents’ ability to claim religious, philosophical or personal exemptions for vaccination.

That’s a pendulum that needs to swing more in the public health protection direction, in the FEHlog’s view.

Congress remains in session this coming week on Capitol Hill. Here’s a link to the Week in Congress’s report on last week’s actions there.  On Tuesday afternoon, the Senate Homeland Security and Governmental Operations Committee will hold a hearing on the President’s nomination of Dale Cabaniss to be Director of the Office of Personnel Management.

Healthcare Dive reports from the American Association of Healthcare Journalists annual conference last week. Interesting observation:

The panel on the retail-ization of healthcare took time to address the elephant of the famously disruptive online retailer [Amazon], with Humana’s [Chief Medical Officer William] Shrank noting insurers were adopting strategies of retailers, but not their goals.  “The discussion of the retailing of healthcare has taken on a life of its own,” Shrank said. “Retail is about increasing consumption; we in healthcare want to reduce unnecessary consumption.”

In that regard, the Boston Globe has a front page article today on the extent of health insurance coverage of proton beam treatment for cancer.

While reading a Wall Street Journal editorial over the weekend, the FEHBlog ran across this useful Peterson Kaiser Health System Tracker.  Check it out.

Well it certainly has been Congressional Budget Office week at the FEHBlog. Yesterday, it was the CBO’s Medicare for All report. Today’s it’s the CBO’s updated report on the budget impact of the Administration’s proposed rule to eliminate prescription drug rebates in the Medicare and Medicaid effective January 1, 2020. It’s much more FEHB relevant read than the M4A report.

Yesterday, the States challenging the constitutionality of the Affordable Care Act and the federal government filed their briefs with the U.S. Court of Appeals for the Fifth Circuit. The FEHBlog shelled out $9 to download the principal briefs from both sides which are available at this link. The Fifth Circuit has accelerated oral argument to mid-July 2019 which presents the distinct possibility that the Supreme Court will hear and decide the case before the national election next year. In the FEHBlog’s view, the Supreme Court will take the case only if the Fifth Circuit sides with the the trial court’s decision that Congress’s decision to zero out the ACA’s individual mandate penalty brought down the whole law. In the FEHBlog’s opinion that the parties defending the law’s constitutionality have the stronger argument.

Sen. Charles Grassley (R NE) announced today that his Finance Committee will hold a hearing next week on the 2017 law popularly known as MACRA that changed the way that Medicare Part B pays doctors.

“I was pleased to support MACRA in 2015. It ended the perpetual cycle of Congress temporarily heading off cuts to Medicare payments to physicians under the flawed Sustainable Growth Rate system, and serves as proof that Congress can tackle big challenges in a bipartisan way. The legislation also reformed how Medicare pays by establishing incentives to reward physicians for providing the best possible care to seniors. This hearing will give senators a chance to hear about how those incentives have been implemented and how well they’re working. Hearing from physicians on the front lines of providing care will be especially helpful in determining what else Congress can do to achieve MACRA’s goals,” Grassley said.

The hear will be held next Wednesday May 8 at 10;15 am on Capitol Hill.

This Robert Wood Johnson Foundation announcement caught the FEHBlog’s eye.  The author who is concerned with rural health care, writes in pertinent part as follows:

At a time when we are trying to understand how ZIP codes influence our health and quality of life, rural people have lessons to share about what it takes to build equity and opportunity in their communities.

Here are lessons I’ve learned in my work with the Robert Wood Johnson Foundation:

• Work with and through local and regional intermediaries. When it comes to making change in rural communities, you have to start with the schools; community-based organizations; regional health centers; faith-based institutions; and small businesses. Small businesses, for example, play a vital role in rural America, creating roughly two-thirds of new jobs and supporting the economic and social well-being of their communities.
• Grow and engage leaders of different kinds and at different levels to get the work done together. This isn’t about another leadership training, but about finding champions in each community and helping them develop the skills they need to facilitate change. In Well-Connected Communities, volunteer leaders are helping their neighbors be healthier at every stage of life by coming together. In Athens, we are learning how to engage new messengers in small and big ways. At our quarterly Civic Saturdays, readers and speakers are strategically selected to bring new voice and experience to our civic rituals.
• Connect people within and across sectors and geographies for peer learning and collective action. When you bring a diversity of perspectives to the table, you are more likely to generate the right energy and strategy around the solutions rural communities need most. Within our own Rural Assembly, we represent a diversity of cultures, geographies, and ethnicities, as well as a diversity in interests and expertise for our hometowns and communities. These range from climate and energy solutions to creative placemaking initiatives, from economic transitions to restoring our democracy.
• Develop and strengthen the infrastructure for local, state, regional and national resource and information-sharing. Urban and rural boundaries are porous and our residents are itinerant; the roads leading in and out carry people, goods, and ideas without regard to ZIP code, making the futures of rural and urban places intertwined.

Yesterday, the House Oversight and Reform Committee held a hearing on the financial condition of the U.S. Postal Service.  The upshot of the hearing according to reports from Govexec.com and the Federal News Network is that the Committee wants a 10 year financial stability plan from the Postal Service before it will move forward with postal reform legislation. The Postal Service is expected to submit the plan to Congress this July.

The Congressional Budget Office released a lengthy report today on policy considerations of single payer legislation. Modern Healthcare observes that the CBO report “largely put a damper on the idea of a U.S. single payer healthcare system.” Check it out.

Last week, the FEHBlog heard Centers for Disease Control experts talk about the importance of including pharmacists in care management teams.  Over 20 years ago, the FEHBlog heard a pharmacist working at a PBM make the same point. She suggested that health plans should compensate pharmacists for their consumer advice. In this regard, its worth pointing out this Forbes article reporting that

[The pharmacy chain] Walgreens has partnered with the National Council for Behavioral Health and the American Pharmacists Association to make training available to Walgreens pharmacy staffers in “mental health first aid,” which those involved say will help assist patients suffering from mental health conditions or substance abuse.

Walgreen’s has given mental health first aid its own website.

It turns out that this is National Childhood Immunization Week and a wide array of Health and Human Services officials are voicing their support for those immunizations.  The FEHBlog heard a helpful discussion on childhood immunizations on today’s Econtalk episode.  Here’s an except:

Emily Oster, a Brown University economics professor:  I think that sometimes in these debates about vaccines you get the feeling that people think the CDC [Centers for Disease Control] is just standing on one side, being like, ‘Oh, it’s fine. Trust us. We’re experts.’ And then the anti-vaccination side can seem more evidence-based, because they are saying, ‘Well, look at these papers. Look at this evidence that we have come up with.’ And I think, you know, that’s not right. The conclusions that the CDC is drawing, and these American Academy of Pediatrics is drawing from, these are really carefully researched. This is a thousand pages which reflects, you know, reviews of thousands and thousands for studies by many, many, many people over a period of many years. And, the conclusion is vaccines are safe and effective. But, it’s not just something people are saying. It is something we have evidence for.

Here’s a related Business Insider article on the ongoing measles outbreak which has reached 704 cases nationwide.

Employee Benefit News identifies a handful of employee wellness program engagement strategies, which make sense to the FEHBlog.

mHealthIntelligence discusses an American College of Physicians (“ACP”) survey on adoption of telehealth by internists.

According to the ACP, survey respondents cited the typical barriers to implementation – reimbursement, licensing and regulations – but they also worried that the technology would be more cumbersome and time-consuming than helpful, and they worried that their patients would not have access to the technology they’d need. 

For its part, the ACP is looking to meet that challenge. The organization plans on making available “practical resources specific to an internal medicine practice,” including guidance on reimbursement, use cases, regulatory guidelines and advice on workflow changes. 

“We hope these resources can help close the gap between physician use of telehealth and patients’ desire for flexibility and access to their physicians,” Tabassum Salam, MD, FACP, the ACP’s vice president for medical education, said in the press release.

Agreed.

Following up on a post about the Association Health Plan (“AHP”) litigation last week. the National of Association of Plan Advisors reports that the U.S. Labor Department (“DOL”) has appealed the adverse ruling against AHPs to the U.S. Court of Appeals for the District of Columbia Circuit. Further, DOL confirmed in a press release issued today that

the Department will not pursue enforcement actions against parties for potential violations stemming from actions taken before the district court’s decision in good faith reliance on the AHP rule’s validity, as long as parties meet their responsibilities to association members and their participants and beneficiaries to pay health benefit claims as promised. Nor will the Department take action against existing AHPs for continuing to provide benefits to members who enrolled in good faith reliance on the AHP rule’s validity before the district court’s order, through the remainder of the applicable plan year or contract term.

Congress returns to work on Capitol Hill this week following a two week break. The FEHBlog had understood that OPM’s Acting Director Margaret Weichert would appear before the House Oversight and Reform Committee on May 1 to provide details on the OPM reorganization.  Federal News Network clarifies that

[While] Weichert was supposed to testify before the committee May 1, and OPM was supposed to provide documents subpoenaed by the committee at the same time [* * * ,] [Rep. Gerry] Connolly [D VA] said Weichert postponed until later in the month, and OPM isn’t providing the documents until she testifies.

The Health and Human Services Office for Civil Rights, which enforces the HIPAA Privacy and Security Rules, delivered good news to HIPAA regulated entities late Friday afternoon by releasing a notice of enforcement discretion concerning HIPAA’s Civil Penalties. OCR rationalized its enforcement policy by aligning the maximum penalty amount with the culpability tier.

According to Modern Healthcare, “the possible penalties for each tier now look like this:

    Tier 1: $100-$50,00 per violation, capped at $25,000 per year the issue persisted
    Tier 2: $1,000-$50,000 per violation, capped at $100,000 per year the issue persisted
    Tier 3: $10,000-$50,000 per violation, capped at $250,000 per year the issue persisted
    Tier 4: $50,000 per violation, capped at $1.5 million per year the issue persisted.”

Previously the maximum penalty was $1.5 million at all culpability tiers.

Healthcare Dive reports that Humana and telehealth provider Doctor on Demand have developed a new virtual primary care program called On Hand. On Hand is integrated with Doctor on Demand’s Synapse platform.

Doctor On Demand’s Synapse platform provides a range of health and wellness services, from preventive health to chronic care, urgent care and behavioral health, all through video visits. The platform also allows patients to access their digital health records and updates, including from connected devices. 

Per DocWire News, Doctor on Demand was created in 2012 by Jay McGraw and his father Dr. Phil McGraw, host of TV’s “Dr. Phil.”

The FEHBlog was surprised to read in Healthcare Dive that the Federal Trade Commission is “suing “Surescripts, accusing the health IT vendor of acting illegally to maintain monopolies in electronic prescription markets for routing orders from providers to pharmacies and for determining patient eligibility for coverage of the drugs.” CVS Health,  Express Scripts, and two pharmacy trade associations own SureScripts. The Dive adds

Surescripts said it processed 1.77 billion transactions last year, a nearly 30% increase from the year before, and touted connections to “virtually all” EHR vendors, pharmacy benefit managers, pharmacies and clinicians. In a statement provided to Healthcare Dive, Surescripts CEO Tom Skelton said the company is cooperating with the investigation and has “operated fairly” for more than 18 years.

 In other words, Surescripts is a model for interoperability.

Healthcare Dive also reports that

Amazon has begun marketing [its subsidiary] PillPack’s at-home prescription drug delivery to Amazon Prime members via email and created a webpage about the service. Some customers reported Tuesday they received emails about the monthly medication delivery service, touting zero shipping costs and increased convenience.