FEHBlog

• The Centers for Medicare and Medicaid Services is proposing to expand Medicare coverage for 

Ambulatory Blood Pressure Monitoring (ABPM).  ABPM is a non-invasive diagnostic test that uses a device to track blood pressure over 24-hour cycles. Ambulatory monitoring allows blood pressure to be measured over entire days rather than at a single moment in time.  ABPM may measure blood pressure more accurately and lead to the diagnosis of high blood pressure (hypertension) in patients who would not otherwise have been identified as having the condition. 

• Becker’s Hospital Review tells us about Optum’s list of five costly drugs that are rolling out this year.  

While the end of HealthVault is an admission of failure for the company’s initial forays into health, Microsoft has refocused its efforts in the industry toward the enterprise market.

The Senate Finance Committee held its prescription benefit manager hearing today. CNBC reports on the hearing here.

Healthcare Dive reports on the comments that were filed on the CMS proposed rule to eliminate prescription drug rebates from Medicare, among other federal health programs offered to the public. The drug manufacturers favor eliminating the rebates. However, they have been unwilling to assure the PBMs and health plans that the rebate savings will lower prescription drug pricing dollar for dollar.

From skimming through the Senate testimony, it’s clear to the FEHBlog that the Medicare rebate rule needs to be withdrawn and re-evaluated. Removing rebates would not create overall healthcare savings even if rebates are fully traded for lower drug prices. It would benefit plan members with high deductibles or co-insurance arrangements for their prescription drug coverage.

Ironically, the commercial PBMs did not originate the rebate idea. The PBMs ripped a page out of the federal government’s playbook which included prescription drug rebate arrangements for Medicaid, the Veterans Administration, and the Defense Department going back at least into the 1980s.

The most effective step that Congress can take to lower prescription drug prices is to reform the patent system for prescription drugs, including specialty drugs.  The UnitedHealthcare witness at today’s hearing explained (p. 6)

An effective intellectual property environment plays an indispensable role in both promoting drug discovery and ensuring innovations are affordable and sustainable. Today’s intellectual property system does not work as intended. The most important step Congress can take to address the high cost of prescription drugs is to modernize the intellectual property system for the 21st century and eliminate drug manufacturers’ ability to manipulate the patent and regulatory system and thereby prevent lower-cost genericsand bio-similars from reaching consumers more quickly 

Amen to that.  If the rebate debate leads Congress to take action to reform the patent laws, the debate will have served its purpose.

Forbes reports that “The venture capital arm of five Blue Cross and Blue Shield plans has partnered with global primary care provider Sanitas USA to open medical centers in Texas as a precursor to a U.S. multi-state rollout.”  That expansion is bound to happen in view of the experience of UnitedHealthcare.

The Associated Press informs us of a new study finding that “Children received prescriptions for antibiotics more than half the time during telemedicine visits, compared with 42% at urgent care clinics and 31% at doctors’ offices.”  It’s not surprising that the providers who best know their patients provide the best care. As pediatric offices begin to offer telemedicine service to their patients, this trend should work itself out. In the meantime, parents should be aware of it.

Healthcare Dive discusses a new government study finding that emergency room use increased in 2016 while emergency room misuse dropped.

The American College of Emergency Physicians celebrated the report’s numbers. EDs play a critical role in healthcare, as nearly two-thirds of emergency visits happen after doctors’ offices are closed, Vidor Friedman, president of the organization, said in a statement.

“Emergency care is growing more complex and some of the larger trends that will impact emergency department planning and resource discussions include the rising number of elderly patients, preventing and treating opioid abuse and the role of the emergency department in treating and managing patients with mental illness,” Friedman said.

The U.S. Justice Department reports that “A federal jury found a South Florida health care facility owner [ Philip Esformes] guilty today for his role in the largest health care fraud scheme ever charged by the Justice Department, involving over $1.3 billion in fraudulent claims to Medicare and Medicaid for services that were not provided, were not medically necessary or were procured through the payment of kickbacks.”  That’s a lot of boxes of ziti (Sopranos reference).

Congress remains in session this week on Capitol Hill. Here’s a link to the Week in Congress’s report on last week’s actions there. Attention will be directed to the Senate Finance Committee on Tuesday morning as the Committee holds a prescription drug pricing hearing with top five prescription benefit managers appearing as witnesses.

Speaking of prescription drugs, Healthcare Dive reports that the CVS pharmacy chain announced last Thursday that

it has expanded its same-day prescription delivery service to 6,000 CVS Pharmacy locations, for $7.99. The drugstore unit, the retail division of CVS Health, began piloting same-day service in 2017 and has been delivering prescriptions nationwide for about a year, according to a company press release. Delivery, often within an hour, is provided through Target-owned same-day delivery company Shipt.

Here’s a link to the CVS press release.

Also, the Wall Street Journal informs us that

The Trump administration said the federal government would offer a risk-sharing system to reimburse health insurers for financial losses resulting from a proposed ban on certain pharmaceutical-industry rebates in Medicare. 

The backstop on most of insurers’ losses could help prevent premiums from rising significantly as a result of the rebate-rule changes, while making taxpayers responsible for a greater share of cost overruns in Medicare’s prescription-drug program. 

The offer to assume most of the financial risk for the loss of the discounts is a sign the administration is likely to proceed with its push to end rebates, and it could address some critics’ concerns. 

Finally, in other news, Health Payer Intelligence relates that

UnitedHealthcare recently announced that it has invested more than $400 million to address the social determinants of health and increase affordable housing access for people in underserved communities. The healthcare payer has invested in more than 80 affordable-housing communities across the US, with more than 4500 homes for people in need.

Federal News Radio offers more details on the House Democrats inquiry into the merger of OPM’s remnants into GSA. The FEHBlog’s money is on Ms. Weichert ultimately convincing Congress about the value of the merger.

To the FEHBlog’s surprise, the Wall Street Journal reports that “A federal judge on Friday said he wants to hear in court from witnesses who object to the Justice Department’s decision last year to approve CVS Health Corp.’s nearly $70 billion acquisition of Aetna Inc.—a highly unusual move that threatens to shake up the already-consummated deal.”  The hearing is expected to last a week sometime next month.

Becker’s Hospital Review discusses Walmart’s successful experts to direct employees to high quality doctors for surgery and cancer care, regardless of cost, because the level of care drives down costs over the long run..  The Boston Globe’s Stat also offers a report from the provider side suggesting that high quality care can lower health care costs.

The Federal Times reports today that

Government Operations Subcommittee Chairman Gerry Connolly, D-Va., sent a letter to acting OPM Director Margaret Weichert March 22 asking her to appear before the committee May 1 to go over detailed plans for the merger that have yet to be disclosed.
In the meantime the members of the Oversight and Reform Committee asked that the Appropriations Committee include language in the FY20 funding legislation to prohibit the use of any funds for an OPM merger, unless the administration can provide detailed plans, analysis of necessary legal authorities, a cost-benefit analysis, confirmation that the administration has addressed all merger recommendations and concerns by the Offices of Inspector General, and a detailed analysis proving that the merger would actually make government more efficient and effective.

The FEHBlog is a fan of the Econtalk podcast. This week the podcast’s host Russ Roberts interviewed philosopher and author Jacob Stegenga of the University of Cambridge concerning his recent book titled Medical Nihilism. Mr. Stegenga advocates for less interventionist gentle medicine. The FEHBlog found the interview to be thought provoking. You can read a transcript here. The FEHBlog also came across this opinion piece from the British Journal of Medicine about the book. The BMJ article’s author observes

The word “nihilism” may be unfortunate. Stegenga and I spoke at a meeting chaired by the president of the Academy of Medical Sciences, where the president objected to the word nihilism, thinking that Stegenga was suggesting that medicine has achieved little and is more of a bad than a good thing. That is not Stegenga’s argument, and he ends his book with some positive ideas on how medical nihilism might lead to better medicine.

He advocates “gentle medicine,” borrowed from the 19th century term la médécine douce. Gentle medicine “encourages a moderate form of therapeutic conservatism.” Many doctors, particularly general practitioners, already practice medicine gently, and gentle medicine clearly overlaps with realistic medicine, prudent medicine, and slow medicine, all of which have their proponents.

On the healthcare information technology front, Amazon announced today that Alexa is not HIPAA compliant. The announcement states that

The new healthcare skills that launched [on Alexa devices]  today are:

• Express Scripts (a leading Pharmacy Services Organization): Members can check the status of a home delivery prescription and can request Alexa notifications when their prescription orders are shipped.
• Cigna Health Today (by Cigna, the global health service company): Eligible employees with one of Cigna’s large national accounts can now manage their health improvement goals and increase opportunities for earning personalized wellness incentives.
• My Children’s Enhanced Recovery After Surgery (ERAS) (by Boston Children’s Hospital, a leading children’s hospital): Parents and caregivers of children in the ERAS program at Boston Children’s Hospital can provide their care teams updates on recovery progress and receive information regarding their post-op appointments.
• Swedish Health Connect (by Providence St. Joseph Health, a healthcare system with 51 hospitals across 7 states and 829 clinics): Customers can find an urgent care center near them and schedule a same-day appointment.
• Atrium Health (a healthcare system with more than 40 hospitals and 900 care locations throughout North and South Carolina and Georgia): Customers in North and South Carolina can find an urgent care location near them and schedule a same-day appointment.
• Livongo (a leading consumer digital health company that creates new and different experiences for people with chronic conditions): Members can query their last blood sugar reading, blood sugar measurement trends, and receive insights and Health Nudges that are personalized to them.

Well that was fast. Yesterday the Senate Finance Committee challenged prescription benefit managers to lower insulin prices and today Cigna’s affiliate Express Scripts was the first to come through according to Healthcare Dive.

Fierce Healthcare reports on yesterday’s Congressional hearing on surprise billing. The FEHBlog’s preference is for the solution under which the hospital requires all doctors who provide care at the facility to participate in the health plans networks used by the hospital.

The Healthcare Payment and Learning Action Network has released a roadmap for high performance in alternative payment models. Check it out.

The Healthcare Cost Institute has informs us that

Where people receive health care matters, especially in terms of costs. The same services may have a much higher price tag when performed in one setting rather than another, but this price difference is rarely publicized to patients. To understand what settings people used and how prices differed, we looked at the utilization and average price paid from 2009 to 2017 for a set of services commonly performed in both physician office and outpatient settings. We found that:

•     The share of these services performed in the outpatient setting increased between 2009 and 2017.
•     For this set of services, the average price was always higher in an outpatient setting than an office setting.

Happy National Employee Benefits Day!

The Office of Personnel Management issued a proposed rule that would amend its Federal Employees Benefits Acquisition Regulation to update certain marketing provisions for the self plus one option and its contract clause matrix. The comment deadline on this proposed rule is May 2, 2019.

The Labor Department released frequently asked questions on the recent federal district court decision torpedoing the agency’s association health plan rule.

The FEHBlog does expect Congress to enact laws this year concerning surprise billing and prescription drug pricing, In this regard, the Wall Street Journal reports today that

“A push to curb surprise medical bills has found support among both Democrats and Republicans on Capitol Hill but also ignited a fight within the health-care industry over how far the federal government should go in regulating prices,” and 

“Smaller profit from the sale of generic drugs is squeezing the two biggest U.S. pharmacy chains, with Walgreens Boots Alliance Inc. joining rival CVS Health Corp. in lowering earnings goals for the year.”

Also the majority and minority leaders of the Senate Finance Committee issued a press release challenging prescription benefit managers to hold down the price of insulin for people with diabetes.

Last month, the senators sent letters to Eli Lilly, Novo Nordisk and Sanofi, the three largest insulin manufacturers in the United States, kicking off their bipartisan investigation into insulin prices.

In their letters today to the PBMs, the senators wrote, “while manufacturers set the list price for insulin, pharmacy benefit managers (PBMs) play a critical role in the pricing of insulin on which people living with diabetes depend…As the primary negotiators for government payers, commercial insurers and individual employers, PBMs are in a unique position to leverage their size to lower drug prices.”

As consumers face rising bills at the pharmacy counter, it is unclear whether PBMs are appropriately leveraging their power for the benefit of taxpayers and patients, especially patients who take multiple or high-cost medications,” the senators continued.

Next week PBM executives will be testifying before this Committee.

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.

Govexec.com reports that late last week the President and OPM moved forward with implementing the pay raise and additional pay localities the Congress recently approved.

“Now that OPM has issued the new pay tables and guidance, agencies and payroll providers will work quickly to update their systems and process retroactive pay actions,” the [OPM] spokesperson said. “The exact timing of implementation may vary. Employees should consult their human resource office or payroll providers for further information.”

In disappointing news for small businesses, a federal judge in Washington, DC, has torpedoed the Administration’s association health plan rule. It’s not clear whether this decision will be stayed while the Administration appeals. Several insured association health plans already have been launched.

Healthcare IT News reports that the America’s Health Insurance Plans is concerned about an HHS proposed rule that would impose new electronic health care information interoperability rules in Medicare, Medicaid, CHIP, and qualified health plans in the federal exchange effective January 1, 2020.  Assuming that the concept is OK, the timing is too rushed.

Following up on a FEHBlog post from a week ago Friday, the Centers for Medicare and Medicaid Services has announced a “Compliance Review Program to ensure compliance among covered entities with HIPAA Administrative Simplification rules for electronic health care transactions.”

In April 2019, HHS will randomly select 9 HIPAA-covered entities—a mix of health plans and clearinghouses—for Compliance Reviews. Any health plan or clearinghouse—not just those who work with Medicare or Medicaid—may be selected. In 2018, HHS piloted the program with health plan and clearinghouse volunteers to streamline the compliance review process and identify any system enhancements. In 2019, providers will be able to participate in a separate pilot program  on a voluntary basis.

Finally, the Cleveland Clinic has named its top 10 healthcare innovations of 2019. Check it out.

It’s been a busy week for the FEHBlog topped off by the 27th OPM AHIP FEHBP carrier conference. Here are some things that the FEHBlog learned from the conference:

• Michael Thompson from the National Alliance of Healthcare Purchaser Coalitions (formerly the National Business Group on Health) spoke about a form of health reimbursement account known as medical episode spending allowances. 

• Dr. Daniel Knecht, Vice President, Clinical Strategy & Policy, Aetna expressed his opinion medication assisted treatment is the gold standard for opioid use disorders.  MAT produces a 50% reduction in mortality compared to non-MAT treatment, but only 1 in 5 affected people receive MAT. Aetna is trying to address that problem.

• Dr. Knecht also mentioned that Exparel is a safe alternative to opioids for oral surgery pain. Oral surgeon can administer the product during surgery. Aetna has been promoting this drug.  Other health and dental plans should take note because at the height of the opioid crisis opioids dispensed due to oral surgery lead to a lot of unnecessary addiction.

• Finally Dr. Knecht noted that Aetna uses a the Alosa Health group from Boston to meet with doctors about evidence-based guidelines.