FEHBlog

The Department of Health and Human Services has finalized the Affordable Care Act 2019 benefit and payment parameter notice.  There is one item in this massive notice that applies to the FEHBP. On pages 332-334, HHS announced that it is finalizing as proposed the 2019 maximum annual limitations on cost-sharing for essential health benefit coverage at $7,900 for self only coverage and $15,800 for other than self-only coverage. This represents an approximately 7% increase above the current 2018 parameters of $7,350 for self only coverage and $14,700 for other than self only coverage.  The CMS press release provides other details on the notice, which loosens restrictions on insurers operating in the individual and small group markets.

Govexec.com reports that the Trump Administration is considering moving 25% of OPM’s responsibilities to other government agencies. “The White House * * * is reportedly weighing the option to move the entire [security] background investigations program to [the] Defense [Department].” What’s more,

“There’s another proposal to move OPM’s Human Resources Solutions, which provides HR services to agencies on a consulting basis, to the General Services Administration. The organization includes a federal staffing center and leadership development program, among other resources.”  

Finally, some actual tidbits

•  The American Hospital Association is encouraging Congress to align a dated federal law (almost 25 yrs older than HIPAA which was enacted in 1996) that protects substance use diagnoses from disclosure (42 CFR Part 2) with the now customary treatment, payment, and health care operations uses and disclosures permitted by the HIPAA Privacy Rule. The AHA explains that  

“Clinicians treating patients for any condition need access to their complete medical histories, including information related to any substance use disorder (SUD), to ensure their patients’ safety, and delivery of the highest quality care. Partitioning a patient’s record to keep SUD diagnoses and treatments hidden from the clinicians entrusted to care for the patient, as required by 42 CFR Part 2, is dangerous for the patient, problematic for providers and contributes to the stigmatization of mental and behavioral health conditions”

• The Alzheimer’s Association has proposed a new approach to drug research for that disease. Focus drug testing on patients who have been diagnosed with the disease using biomarkers rather than on patients with Alzheimer’s symptoms, such as cognitive impairment which can have many causes. The work stemming from mapping the human genome has lead to the discovery of many such biomarkers. ” The authors envision that defining Alzheimer’s disease as a biological construct will enable a more accurate understanding of the sequence of events that lead to the cognitive impairment associated with Alzheimer’s disease, as well as the multiple causes of the disease. This will enable a more precise approach to therapy trials including focusing more specific targets and including the appropriate people.” Evidently this approach has worked successfully with other complicated diseases.

The FEHBlog wraps up a pleasant long weekend with family in Minneapolis tomorrow.  Like the FEHBlog, Congress returns to Capitol Hill tomorrow following a two week long recess. Modern Healthcare reports that Congress is nearing the finish line on legislation to address the opioid crisis that goes beyond funding.

Health Payer Intelligence tells us about new payer approaches to incorporating preventive care and wellness initiatives into their holistic health programs intended to help people avoid or control chronic disease. Good luck with that worthy effort.

The Associated Press reports that last week a federal judge in Alabama issued a ruling in an antitrust case against the Blue Cross Blue Shield Association, The federal judge “agreed to let plaintiff lawyers move ahead with allegations that some actions by 36 [Blue Cross] state insurance operations could amount to an automatic violation of antitrust laws.”  The Wall Street Journal adds that

The case has a long way to go. [The lawsuit was filed in January 2013.] The judge left open at least one potential defense for the insurers’ actions, and the lawsuits against the Blue insurers haven’t yet been certified to proceed as class actions, an issue that could take several more months to resolve.

The AP story notes that “An attorney for the Blue Cross Blue Shield Association, Scott Nehs [actually the Association’s general counsel], says the organization will appeal.” Furthermore, according to the Journal,

the new ruling also held some positive aspects for the insurers. The judge ruled that another aspect of the Blue companies’ cooperation, a program that involves working together to offer national insurance plans [e.g., the Blue Cross Federal Employees Plan] wasn’t an automatic antitrust violation. He also said it wasn’t yet clear whether the Blue insurers effectively operate as a single entity, which could shield their actions against the antitrust allegations.

It’s not easy being a health insurer.

The FEHBlog is out in chilly Minneapolis for a family event. Brr.

Yesterday, the U.S. Surgeon General, Dr. Jerome Adams, issued an opioid crisis related advisory, the first Surgeon General advisory since 2005.  The Surgeon General is encouraging wider distribution of naloxone a life saving medicine which can reverse the effects of an opioid overdose until EMTs arrive. OPM had a session on this topic at the recent carrier conference. Naloxone is dispensed as a nose spray. The Surgeon General explained that

Naloxone is already carried by many first responders, such as EMTs and police officers. The Surgeon General is now recommending that more individuals, including family, friends and those who are personally at risk for an opioid overdose, also keep the drug on hand.

All states have passed laws to increase access to naloxone and, in most states, you can walk into a pharmacy and request naloxone even if you don’t already have a prescription. In addition, most states have laws designed to protect health care professionals for prescribing and dispensing naloxone from civil and criminal liabilities as well as Good Samaritan laws to protect people who administer naloxone or call for help during an opioid overdose emergency. 

Naloxone is covered by most insurance plans and, for those without coverage, may be available at low or no cost through local public health programs or through retailer and manufacturer discounts. It is easy to use, safe to administer and widely available. 

The Kaiser Family Foundation issued a large employer survey on the opioid crisis. Prescriptions are down significantly but treatment costs are skyrocketing. Here’s a link to a Healthcare Dive report on the KFF report.

Fierce Healthcare reports that CVS Health, which has been holding a client forum this week, “kept price growth at only 0.2% for pharmacy benefit management clients despite 10% inflation, according to a report (PDF) the company released on Thursday. The lower cost growth was due in part to utilizing low-cost generic drugs, which were dispensed to 86% of pharmacy benefit management (PBM) clients. ”  Maazal tov.

Employee Benefit News suggests three ways to boost health savings account participation. The best tidbit is to “don’t just talk about HSAs around open enrollment. Reach out consistently, whenever your employees are best primed to care: at the beginning of a new plan year; in March and April when tax savings are front of mind; or after a pay raise or promotion.”

Finally, the Departments of Health and Human Services and Justice released today that “a fiscal year (FY) 2017 [which ended September 30, 2017) Health Care Fraud and Abuse Control Program report showing that for every dollar the federal government spent on healthcare related fraud and abuse investigations in the last three years, the government recovered $4. Additionally, the report shows that the departments’ FY 2017 Takedown event was the single largest healthcare fraud enforcement operation in history.”

The FEHBlog enjoys tracking healthcare trends. Here’s the latest:

• Good trend — Kaiser Health News reports that the Centers for Medicare and Medicaid Services is authorizing Medicare Advantage supplemental coverage for services and supplies that help Medicare Advantage plan beneficiaries live happier, more independent lives. 

“CMS is catching up with the rest of the world in terms of its understanding of how we keep people healthy and well and living longer and independently, and those are all positive steps,” said Ceci Connolly, chief executive officer of the Alliance of Community Health Plans, which represents nonprofit health insurance plans. Some offer non-emergency medical transportation, low-cost hearing aids, a mobile dental clinic and a “grocery on wheels,” to make shopping more convenient, she said. 

UnitedHealthcare, the largest health insurer in the U.S., also welcomes the opportunity to expand benefits, said Matt Burns, a company spokesman. “Medicare benefits should not be one-size-fits-all, and continued rate stability and greater benefit design flexibility enable health plans to provide a more personalized health care experience,” he said.

Given the older demographics in the FEHBP, the FEHBlog expects such extra benefits to appear in the FEHBP before long.

• Good trend –The HHS Office of National Coordinator for Health Information Technology released the ONC Guide to Getting and Using your Health Records, a new online resource for individuals, patients, and caregivers. Check the site out.

• Bad trend — Fierce Healthcare reports that “New nationwide surveillance discovered hundreds of antibiotic-resistant ‘nightmare bacteria,’ officials from the Centers for Disease Control and Prevention warned this week as they urged local governments to help in the effort to fight superbugs.”  What’s more — “Antibiotic-resistant superbugs are an expensive problem—with costs topping $2 billion per year based on some estimates—and are deadly, on track to kill more people than cancer by 2050. In addition to the containment strategies outlined by the CDC, providers can hinder the spread of these bugs by being more judicious with antibiotic use.” Ruh roh. 

OPM’s recently installed Director, Dr Jeff Pon, and Deputy Director, Michael Rigas, posted a video for civil servants last week. For people like the FEHBlog who are involved with OPM, it was useful to watch the video to get a flavor for their respective management philosophies.

Thanks to Fortune Magazine, the FEHBlog ran across this eclectic Opioid Watch news feed from the Opioid Research Institute.  One of the articles promotes the study of human waste to identify neighborhoods with high opioid use, known as hotspotting. According to the article this investigative technique which is already popular in Europe has made its way across the pond. Hotspotting is considered more reliable than personal surveys.

In this regard, it’s worth adding that this is National Public Health Week in the U.S.

Forbes reports on the technology front that

An effort to apply blockchain technology to improve inaccurate doctor directories of health plans is the goal of a new partnership between UnitedHealth Group and its Optum unit, Humana, Quest Diagnostics and MultiPlan. 

The healthcare companies have no plans to develop bitcoin or a form of cryptocurrency. Rather, healthcare companies involved in a pilot program announced Monday are going to use blockchain’s ability to secure data and distribute it in an encrypted way to make sure the most current information is available in health plan provider directories.

Good luck.

Last Thursday, the U.S. Centers for Disease Control issued its latest report on opioid overdose deaths:

Drug overdoses killed 63,632 Americans in 2016. Nearly two-thirds of these deaths (66%) involved a prescription or illicit opioid. Overdose deaths increased in all categories of drugs examined for men and women, people ages 15 and older, all races and ethnicities, and across all levels of urbanization. 

CDC’s new analysis confirms that recent increases in drug overdose deaths are driven by continued sharp increases in deaths involving synthetic opioids other than methadone, such as illicitly manufactured fentanyl (IMF). 

“No area of the United States is exempt from this epidemic—we all know a friend, family member, or loved one devastated by opioids,” said CDC Principal Deputy Director Anne Schuchat, M.D. “All branches of the federal government are working together to reduce the availability of illicit drugs, prevent deaths from overdoses, treat people with substance-use disorders, and prevent people from starting using drugs in the first place.” 

CDC’s analysis, based on 2015-2016 data from 31 states and Washington, D.C., showed:
Across demographic categories, the largest increase in opioid overdose death rates was in males between the ages of 25-44. 

• Overall drug overdose death rates increased by 21.5 percent.
• The overdose death rate from synthetic opioids (other than methadone) more than doubled, likely driven by illicitly manufactured fentanyl (IMF).
• The prescription opioid-related overdose death rate increased by 10.6 percent.
• The heroin-related overdose death rate increased by 19.5 percent.
• The cocaine-related overdose death rate increased by 52.4 percent.
• The psychostimulant-related overdose death rate increased by 33.3 percent.
• IMF is mixed into counterfeit opioid and benzodiazepine pills, heroin, and cocaine, likely contributing to increases in overdoses involving these other substances.

The report further notes that “Eight states had significant increases in death rates involving prescription opioids. West Virginia, Maryland, Maine, and Utah had the highest rates.”

Happy Easter! Both the House and the Senate have work periods in their home districts / states this week.

The Wall Street Journal today has an enlightening story about the Walmart-Humana merger currently under discussion.

“These vertical deals [e.g. CVS Health -Aetna, Cigna-Express Scripts] are super exciting, mostly for the potential to keep people out of the hospital,” said Zack Cooper, health economist at Yale University.
With a potential Walmart-Humana deal, “there is scope for this new entity to, in a sense, offer a product that has less bells and whistles and is more efficient and lower cost,” he said.
Outside its pharmacies—which operate across 4,700 U.S. Walmart stores—the retailer’s health-service offerings are currently limited. Walmart operates 19 clinics in Georgia, South Carolina and Texas and other providers operate about 50 additional clinics. But Walmart’s expansive retail footprint would make it a formidable competitor should it build out low-cost outpatient offerings, said industry executives and consultants.

In contrast, CVS Health has over 9,800 pharmacies in 49 states, DC, and Puerto Rico (The only state currently without a CVS pharmacy is Wyoming.)

At the OPM carrier conference last month, a speaker on the opioid panel observed, and they New York Times confirmed, that dentists are the leading prescribers of opioid based pain killers to children and young adults aged 10 to 19.  Last week, the American Dental Association announced a new policy supporting statutory opioid prescription limits and continuing education for the members.

Cigna announced “a 25 percent reduction in opioid use among its customers, reaching this key metric one year ahead of its ambitious initial goal” made in 2015.

Becker’s Hospital Review reports on a survey finding the phishing hackers are moving to new tactics:

1. Attacks that are “fileless,” leveraging exploits and scripts rather than installing malicious files. These fileless techniques attempt to bypass traditional security measures that focus on scanning files, such as antivirus solutions.

2. Attacks that are “clickless,” meaning they do not rely on tricking users into selecting a malicious application. Instead, these attacks take advantage of vulnerabilities to deploy remote execution exploits to infect computers.

3. Attacks that misuse legitimate system tools and processes already present on a computer, rather than deploying malicious files. Since these attacks take advantage of legitimate pathways, they are more difficult for many security measures to detect.

4. Attacks with built in “worm” capabilities. A worm, which is a type of contagious malware, will infect software and copy itself without the need for user action. Its goal is to spread malware infections quickly, and.

5. Attacks that leverage “cryptomining” to receive their payloads. In these attacks, a cyberattacker deploys cryptomining malware on a target’s computer to process cryptocurrency transactions without the user’s knowledge.

Fierce Healthcare reports that 

The Department of Health and Human Services (HHS) has created two new positions to lead efforts to bring down prescription drug costs and confront the opioid epidemic.
Daniel M. Best, the former corporate vice president of industry relations for CVS Health’s Medicare Part D business, will serve as senior adviser to the secretary for drug pricing reform. Brett Giroir, M.D., will add to his duties as the assistant secretary for health, serving in a dual role as a senior adviser to the secretary for mental health and opioid policy. The appointments represent two of the four priorities HHS Secretary Alex Azar recently laid out as part of a “transformation agenda” for the agency.

 Good luck to these gentlemen.

Speaking of the opioid crisis, Modern Healthcare reports that

The Blue Cross and Blue Shield Association has adopted a new standard that opioids should not be the first or second treatment options to manage pain, mirroring guidelines set by the Centers for Disease Control and Prevention.

In most cases, ibuprofen and acetaminophen can treat pain more effectively than opioids, said Dr. Trent Haywood, chief medical officer for the Blues association, which has about 106 million members. It’s important that physicians understand that alternatives like medication-assisted treatment exist, which pairs medication with behavioral counseling, he said.

It’s not an absolute decree. In many cases, particularly related to cancer treatment or end-of-life care, opioids may be the best remedy, said Haywood, adding that the association will aid physicians in making the best clinical decision.

And, on the business trends front —

• Healthcare Payer Intelligence informs us that 

A group of commercial payers and other healthcare organizations have formed a coalition to explore how addressing the social determinants of health can lower care costs and improve outcomes.  A number of large payer companies have joined the Aligning for Health (AFH) coalition, including the BlueCross BlueShield Association, CareSource, Humana, UPMC Health Plan, and WellCare. AFH stakeholders cited research that suggests social factors including access to healthy food, safe housing, and financial security account for nearly 70 percent of all health outcomes. Addressing these social factors can have positive effects on healthcare outcomes, costs, and utilization, the coalition said.

•  Health Leaders Media explains that 

Insurers and employers are recognizing the value of providing a consumer advocate who can work directly with a consumer, supported by a team of multidisciplinary professionals, says Tom Meier, vice president of market solutions at Health Care Service Corporation (HCSC), a consumer-owned health insurer in the United States and a licensee of Blue Cross Blue Shield, serving nearly 15 million members.

The increased interest comes partly from the realization that the higher deductibles currently in use don’t make consumers more thoughtful and engaged in using healthcare resources wisely, as many employers hoped, according to a recent healthcare industry survey. Instead, they just make them avoid healthcare altogether, including preventive healthcare.

Some health plans are developing health advocacy programs, and there are companies such as Accolade that offer services to both employers and health plans. Accolade promises employers savings of up to 15% and says health plans can improve utilization and the member experience while reducing medical claims spend.

HCSC is addressing those goals with a program called Health Advocacy Solutions for large employer customers. It’s a personal concierge program to address healthcare issues, answer questions, and encourage members to become advocates for their own health, Meier says. 

The FEHBlog is concerned about the lack of interoperability in electronic medical records. Last evening he ran across this Sure Scripts service which helps bridge interoperability gaps by using its vast database of prescription records to locate related medical providers for specific patients (fully HIPAA compliant of course). Apple has taken a different tack by transmitting a patient’s medical records for about 40 facilities directly to their i-phones. Very cool.

The Wall Street Journal reports this evening that Walmart, which offers retail pharmacy services, in in early talks to buy health insurer Humana. According to the Journal, “The talks come as health-service providers are rapidly pairing off and retailers—particularly pharmacy chains—are looking to diversify and bulk up in the face of the competitive threat from e-commerce giant Amazon.com Inc.”

Aetna announced that like United Healthcare it will be sharing prescription drug manufacturer rebates with fully insured commercial plan members at the point of sale next year. Fierce Healthcare noted HHS Secretary Alex Azar quickly complimented Aetna’s decision on Twitter.

OPM’s community rated contracts with Aetna’s and UHC’s HMOs participating in the FEHBP would permit those carriers to extend this new practice to FEHBP enrollees. OPM’s experienced rated contracts with nationwide carriers don’t allow this flexibility. That’s unfortunate.

Avik Roy in Forbes offers Secretary Azar some advice on how to accomplish the desired healthcare system change to patient driven care.

As Azar himself as admitted, moving to a more patient- and consumer-driven “will require some degree of federal intervention,” he said, “perhaps even an uncomfortable degree…but the status quo is far from a competitive free market…facilitating a competitive, value-based marketplace is going to be disruptive to existing actors.”
This will be the acid test of Azar’s leadership at HHS. Too often, Republicans have accepted the health care status quo, under the premise that changing the status quo would require–egads!—federal intervention.
But federal intervention—of the wrong kind—is the fundamental reason why American health care is so costly today. It will take meaningful policy changes—both by Azar’s agency and by Congress—to repair 70-plus years of Washington’s handiwork.

Mr. Roy suggests simplifying federal laws to allow patients to get and share their health care data, work with the Justice Department and the Federal Trade Commission to improve competition and less consolidation among healthcare providers, and cut drug prices for consumers like these UHC and Aetna moves will do.

Fierce Healthcare also reports on an interesting CNBC interview with Aetna’s CEO Mark Bertolini.

What do Aetna CEO Mark Bertolini and Warren Buffett of Berkshire Hathaway agree on regarding healthcare? It’s stranglehold on the economy.
“Warren Buffett said healthcare is a ‘tapeworm’ on the U.S. economy. It’s true,” Bertolini said Monday on CNBC. Taming that tapeworm will require a shift towards community-focused health, he added.
Bertolini was referencing Buffett’s statement earlier this year when the Berkshire Hathaway CEO announced a healthcare venture with Amazon and JPMorgan. Buffett said he believes the private sector can have more success in lowering healthcare costs than the federal government.

Ditto.  The FEHBlog is concerned that the ACA’s “consumer protections” will complicate Buffett’s efforts as it does for other health plans. In that vein, Mr. Bertolini added that “he hopes combining the three massive companies on the project will yield good results due to the necessary resources needed. ‘I’m hopeful, but don’t expect any miracles,’ he added. “

Finally, a couple of new surveys:

• Becker’s Hospital Review discusses a WalletHub survey identifying the ten best and ten worst states for physicians. 
• The same publication discusses a U.S. News survey identifying the 36 healthiest counties in our country.