FEHBlog

Today, OPM announced the 2019 FEHBP and FEDVIP premium changes which waves the green flag for FEHBP and FEDVIP plans to start communicating about their 2019 benefits and premiums initially on their websites. According to this comprehensive Washington Post story, the average FEHBP enrollee contribution increase is a mere 1.5%, the lowest increase in over 20 years. The government contribution increase is 1.2%. OPM will have it online FEHBP comparison tool ready for 2019 as we get closer to the start of Open Season on November 12, 2018.

Modern Healthcare reports that the Congressional conference committee finished its work on the opioid crisis remedial legislation (H.R. 6) yesterday evening. Of note, the final bill does not include a pharmaceutical manufacturers proposal to partially restore the Medicare Part D donut hole (good outcome) or a healthcare industry proposal to align the unnecessarily complicated substance use disorder privacy law (42 CFR Part 2) with the generally applicable HIPAA Privacy Rule (mystifying outcome).

Healthcare Dive informs us about CVS Health’s plans for its acquisition of Aetna.  For example,

Executives described how they could use its existing services to better serve Aetna’s members. As soon as the deal closes, if it does, CVS believes it will have immediate access to 20% of Aetna’s membership currently using the stores. That matters because CVS believes its pharmacists play a crucial role in shaping a patient’s overall behavior. CVS said many investors underestimate the role of the pharmacist. 

The new, cheaper versions of Gilead’s Epclusa and Harvoni will cost $24,000 for a course of treatment, the Foster City, California-based company said in a statement on Monday. When Harvoni came on the market in 2014, Gilead set a list price of $94,500. Epclusa was approved for sale in 2016, with a price of $74,760.

As the FEHBlog has previously noted, while the original list prices were stunning, curative drugs are taken for a relatively short time frame. Typical blockbuster drugs like statins are taken for years and years. Hopefully more curative drugs for potentially fatal illnesses were be forthcoming and in the meantime the market can figure out a Goldilocks solution.  Easier said than done.  But for now it’s good to see generic level pricing for these drugs.

Health Affairs offers an interesting analysis of the bipartisan surprise bill legislation recently circulated for comment by a group of Senators (as noted in a recent FEHBlog post).

This bipartisan draft legislation marks an important step forward in putting an end to surprise out-of-network medical bills nationwide. As work proceeds on this issue, lawmakers should focus on:

• Determining the appropriate payment rate from the health plan to the provider in these instances, specifically considering a lower rate than the 125 percent of average allowed amounts in a region currently in the draft (and if using any percentile of average allowed or contracted amounts, pegging this calculation to a point in time before passage of the bill, inflated forward);
• Narrowing the protection for all out-of-network services at an in-network facility to those most likely to involve surprise bills; and
• Adding a protection for out-of-network ambulance bills. 

This should be the week that OPM announces the 2019 government contribution toward FEHBP coverage and plans disclose that 2019 enrollee premiums and benefit changes. Woo hoo!

Congress also will be in session on Capitol Hill. Here’s a link to the Week in Congress’s report on last week’s actions on the Hill. The FEHBlog is ecstatic that he found a website that reports on the bills, etc., that Congress is expected to consider this coming week. The Hill newspaper used to have such a weekly report. Today the FEHBlog found it on the Countable website.

The Senate Health Education Labor and Pensions Committee will hold its fourth hearing on reducing health care costs this coming Thursday at 10 am. The subtopic will be improving affordability through innovation. The FEHBlog’s current preferred source for innovative ideas is the Health Payer Intelligence website.

Tomorrow, the U.S. Supreme Court will convene for its so-called super conference in anticipation of opening its October 2019 session next week. The orders from this conference will be released on Thursday.

Earlier this week after the Senate passed HR 6, the opioid crisis relief bill, with an amendment, the FEHBlog understood that a conference report reconciling the House and Senate versions of the bill would be forthcoming this week. Not so fast. Press reports indicate that reconciliation negotiations continue. Modern Healthcare states that “Talks are likely to push into the weekend and possibly until Monday.”

Health Affairs Blog previewed a Health Care Cost Institute study of employer sponsored heath plan costs over the period 2007 through 2016.

The authors found that total enrollee spending (not including premiums) on health care goods and services increased by 44 percent over the decade—from $3,752 to $5,394 per person—which was an average annual increase of 4.1 per cent. They also observed that growth rates slowed after 2009 but increased between 2014 and 2016.

The study also found that enrollee out of pocket spending kept pace with total spending, up 43% over the same period.

Forbes reports on Mercer consulting’s preliminary projection  that large employer health plan costs will rise 4.1% next year and Avalere consulting’s projection that ACA exchange plan premiums will increase 3.1% in 2019. Plansponsor.com digs into some employer sponsored plan trends identified in the Mercer report.

Becker’s Hospital News summarizes a fascinating, detailed Wall Street Journal story about how big health systems use their leverage to create exclusive contracts with various payers, thereby impairing competition. According to the Journal,

Dominant hospital systems use an array of secret contract terms to protect their turf and block efforts to curb health-care costs. As part of these deals, hospitals can demand insurers include them in every plan and discourage use of less-expensive rivals. Other terms allow hospitals to mask prices from consumers, limit audits of claims, add extra fees and block efforts to exclude health-care providers based on quality or cost.

The Wall Street Journal has identified dozens of contracts with terms that limit how insurers design plans, involving operators such as Johns Hopkins Medicine in Maryland, the 10-hospital OhioHealth system and Aurora Health Care, a major system in the Milwaukee market. National hospital operator HCA Healthcare Inc. also has restrictions in insurer contracts in certain markets.

 No bueno.

Today, the Surgeon General spotlighted government efforts to alleviate the opioid crisis.

The federal government has been working with key stakeholders to address this problem and is seeing real progress. This week, HHS disbursed more than $1 billion in opioid-specific funding for states, which includes State Opioid Response grant programs administered by SAMHSA to support a comprehensive array of prevention, treatment, and recovery services. Additional funding from the Health Resources and Services Administration (HRSA) went to community health centers to increase access to substance abuse disorder and mental health services, to increase  the number of professionals and paraprofessionals who are trained to deliver integrated behavioral health and primary care services as part of health care teams in HRSA-supported health centers as well as to rural grantees to increase services and develop plans to implement evidence-based opioid use disorder prevention, treatment and recovery interventions.  There are signs that efforts to stem the opioid crisis are having success, with the use of medication-assisted treatment growing significantly and the number of Americans initiating heroin use dropping significantly from 2016 to 2017.

Bueno.

Earlier this week, the Centers for Medicare and Medicaid Services announced “a proposed rule to relieve burden on healthcare providers by removing unnecessary, obsolete or excessively burdensome Medicare compliance requirements for healthcare facilities. Collectively, these updates would save healthcare providers an estimated $1.12 billion annually. Taking into account policies across rules finalized in 2017 and 2018 as well as this and other proposed rules, savings are estimated at $5.2 billion.”  The FEHBlog is a big fan of deregulation and would be pleased to see OPM catch the deregulation bug.

Congress is on course to wrap up its work on Capitol Hill before the end of September.

Fortune reports that yesterday the Senate by a 99-1 vote has joined the House in a passing a bill (H.R. 6, as amended) responding to the opioid crisis. Congressional leaders expect to release a consolidated bill on Friday which will be enacted early next week. On a related note, Opioid Watch tells us about a recent government report finding that

The number of new heroin users fell by more than half in 2017, according to the latest national drug survey, which was unveiled Friday. “One of the most important findings,” said SAMHSA chief Elinore McCance-Katz in announcing the results in a webcast, “is the very steep decline in new users of heroin from 2016.” New initiates to that drug dropped from 170,000 to 81,000.

Progress finally.

Per Federal News Radio, the Senate today approved a minibus appropriations conference report bill for defense, health, and education functions (H.R. 6157), by a 93-7 vote. The bill also includes a continuing mop-up appropriation measure to keep the government fully funded at least until December 7, 2018. Meanwhile the House and Senate conferees continue to work on the treasury and general government minibus which includes OPM and FEHB appropriations.

In other Capitol Hill news:

• Fierce Healthcare reports that the Senate passed a bill (S. 2554) yesterday by a 98-2 vote that “would stop contracts between pharmacy benefit managers and pharmacies from barring pharmacists from informing patients when they might pay less for a prescription out of their own pocket than if they used their insurance.”
• The Hill reports that a bipartisan group of powerful Senators has released a discussion draft of a bill to protect consumers against surprise bills in emergency care situations, e.g, the hospital is in-network but the contracted emergency care physicians group is out-of-network.  

Forbes reports that the U.S. Justice Department today “has cleared [from an antitrust law perspective] the pending merger [ of Cigna and Express Scripts], “terminating the applicable waiting period” following a six-month review.  The Justice Department explains

In particular, the Division analyzed whether the merger would: (1) substantially lessen competition in the sale of PBM services or (2) raise the cost of PBM services to Cigna’s health insurance rivals.  PBM services are sold to employers and health insurance companies to manage their pharmacy benefits, which can include designing formularies, processing prescription claims, and providing access to pharmacy networks and pharmaceutical rebates.  

The merger is unlikely to lessen competition substantially in the sale of PBM services because Cigna’s PBM business nationwide is small.  The Division also determined that the proposed transaction is unlikely to lessen competition substantially in markets for customers because at least two other large PBM companies and several smaller PBM companies will remain in the market post-merger.  

In evaluating whether the merger may harm competition for the sale of PBM services, the Division understands that Cigna intends to use ESI for PBM services and that Cigna’s current PBM services provider, UnitedHealthcare’s subsidiary Optum, will be free to compete for PBM customers that purchase medical insurance from Cigna upon closing of the transaction. 

Forbes notes that “The Cigna-Express Scripts deal still faces scrutiny in several states. Two weeks ago, Cigna said 14 of 29 states have signed off on the merger.” But this is a big boost toward closure.

The Justice Department continues to consider the CVS Health acquisition of Aetna. Fierce Healthcare reports on CVS Health Chief Executive Officer Larry Merlo’s recent comments on that pending transaction.

Fierce Healthcare informs us about ongoing merger talks between Walmart and Humana.

“We continue to explore opportunities with them, we’ll do that,” [Humana Chief Financial Officer Brian] Kane said. “I genuinely don’t know the answer to that question yet, I think we’re going to learn more in relatively short order.” 

The conversation on Friday also provided plenty of details about Humana’s emerging partnership with Walgreens, where it plans to add providers and “health advisers” in pilot stores in Kansas City.  These providers—employed by Partners in Primary Care, which is Humana’s wholly owned clinic brand—will be set up in a risk-based relationship with Humana’s members so they can seek care directly at the pharmacy.

Congress remains in session on Capitol Hill this week. Here’s a link to the Week in Congress’s report on last week’s activities on the Hill.

We are halfway through the month of September.  The Medicare Advantage Open Season starts in about a month. Investment News reports on projections about the 2019 Medicare COLA (2.8%) and 2019 Medicare Part B premiums.

The latest Medicare Trustees’ report projects that basic Medicare Part B premiums will increase by about $1.50 a month to $135.50 per month in 2019 [roughly 1.2%}. The official Medicare premiums will be announced in the fall. High-income retirees pay more, in some cases much more, for the same Medicare coverage.

The final Social Security COLA will be announced shortly after October 11. Next year’s Medicare Part B premiums are usually announced in November.

If recent history is any guide, OPM will be announcing the 2019 FEHBP government contribution and FEHB plans wills start announcing the 2019 benefit and enrollee contributions during the week beginning September 24.

Fortune informs us that “a new report from Trust for America’s Health and Robert Wood Johnson Foundation breaks down the most recently available obesity statistics, based on Centers for Disease Control (CDC) data, on a state-wide, and sobering, basis, finding that seven U.S. states have adult obesity rates that exceed 35%.”

More comprehensive coverage for mental healthcare could bring a financial return of four dollars for every one dollar spent by employers, says a report from the National Alliance of Healthcare Purchaser Coalitions (NAHPC).

Lawmakers reached a bipartisan deal on Thursday to keep the government open until after the midterm elections, while also passing a first tranche of spending bills and sending them to President Trump’s desk.

The House passed the package of bills, known as a “minibus,” in a 377-20 vote Thursday afternoon, a day after the Senate passed the same package. House and Senate negotiators from both parties had hammered out an agreement on the three spending bills earlier this week, which includes funding for the Energy Department, Veterans Affairs and the legislative branch of government, and their passage puts Congress on pace to avoid the deadline dramas of the past decade.

The House and Senate conferees are meeting about two other minibus appropriations bills, one of which includes FEHBP financing.  Here’s a link to Govexec.com’s minibus report which understandably focuses on whether federal employees will receive a pay increase in 2019. The answer will be found in the same minibus the covers FEHBP financing.

Fierce Healthcare tells us that physicians expressed their great displeasure with CMS’s proposed Medicare Part B fee rule for 2019.

The plan would collapse payment rates for eight office visit services for new and established patients down to two each. Doctors also offered comments. “This is a ridiculous proposal that will only be a detriment to patients and providers alike,” said one anonymous commenter.

A geriatrician who cares for patients with multiple, complicated medical issues said he could see no benefit from the proposal. “It does not make sense to assign the same payment for both a 15-minute visit for a 20-year-old with no known issues and no complaints and for a 40-minute visit for an 80-year-old with a multitude of acute and chronic illnesses,” he wrote.

The American Medical Association submitted 136 pages of comments. How was the play Mrs. Lincoln?

In other medical news, the Association of American Family Physicians announced its support for  “ACT for Better Diagnosis,(betterdiagnosis.org) an initiative of the Society to Improve Diagnosis in Medicine (SIDM) that launched Sept. 13 and aims to improve the diagnostic process by calling on organizations to identify and spread practical steps to better ensure diagnoses are accurate, communicated and timely.”

Members of the Coalition to Improve Diagnosis have collaborated for months to identify initial obstacles they think impede diagnostic accuracy, such as:

• Incomplete communication during care transitions — When patients are transferred between facilities, physicians or departments, there is potential for important information to slip through the cracks.
• Lack of measures and feedback — Unlike many other patient safety issues, there are no standardized measures through which hospitals, health systems or physicians can understand their performance in the diagnostic process to guide improvement efforts or to report diagnostic errors. Providers rarely get feedback if a diagnosis was incorrect or changed.
• Limited support to help with clinical reasoning — With hundreds of potential explanations for any one symptom, clinicians need timely, efficient access to tools and resources to assist in making diagnoses.
• Limited time — Patients and their caregivers overwhelmingly report feeling rushed by limited appointment times, which poses real risks to gathering a complete history that is essential to formulating a working diagnosis; such time constraints also allow scant opportunity to thoroughly discuss any further steps in the diagnostic process and set appropriate expectations.
• The diagnostic process is complicated — There is only limited information available to patients about which questions to ask, who to notify when changes in their condition occur or what constitutes serious symptoms. It’s also unclear who is responsible for closing the loop on test results and referrals and how to communicate follow-up.
• Lack of funding for research — The impact of inaccurate or delayed diagnoses on health care costs and patient harm has not been clearly articulated, and only a limited amount of published evidence exists to aid in identifying what improves the diagnostic process.

Widespread rates of poor consumer literacy within the healthcare industry creates administrative burdens for payers and contributes to an additional $4.8 billion in health plan costs, according to a new Accenture report.

The Federal Times reports that OPM is conducting its third survey (since 2014) of federal agency employee wellness programs. The survey is called WellCheck. How the FEHBlog wishes that OPM would do a better job coordinating the wellness programs of federal agencies and the FEHBP.