FEHBlog

From time to time, the FEHBlog has reminded readers of a truism — science is as much an art as a science.

Yesterday, after completing an outstanding recent biography of our first Chief Justice John Marshall (“Without Precedent: Chief Justice John Marshall and His Times by John Richard Paul, after all the FEHBlog is a lawyer), he started reading Kenneth A. Fisher, M.D.’s book titled “Understanding Healthcare: A Historical Perspective.”

Right there in the introduction a quote which forms the basis for this truism:

“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” Sir William Osler (1849 – 1919).

Dr. Fisher goes on to state in the introduction that

No matter how much science advances our knowledge of the mechanisms of disease, however, medicine remains an art, combining science with humanity to address each individual’s specific needs. “As essential, as invaluable as was the study of specific diseases through close, scientific investigation,” eloquently observed Dr. Oliver Wendell Holmes [(1809 – 1894, whose son was the Supreme Court Justice O. W. Holmes, Jr.)], “there had to be more to the physician’s comprehension and approach. There had to be concern for and some understanding of the patient. Medicine was a science to be sure, but also an art, the noblest of arts.” 

How true that is.  The FEHBlog submits that you cannot assess that expertise in an NCQA HEDIS measure or a CAHPS survey question.

Congress is out of town until April 2. Here’s a link to the Week in Congress’s report on last week’s actions on Capitol Hill.

Healthcare Dive has an interesting article on the millenial generation’s (DOB between 1980 and 2000) attitudes on healthcare delivery. The article is based on this recent EBRI survey.

Healthcare Payer Intelligence reports that

Payers and employers who offer high-deductible health plans (HDHPs)
to attract low-cost members may need member engagement strategies to
generate higher value for these beneficiaries.

Member engagement is critical for HDHP success because low premiums
aren’t enough to keep members satisfied, says Jeff Oldham, Senior Vice
President of Global and Institutional Markets at Benefitfocus, believes
that.

Member engagement was a key theme of OPM carrier conference last week.  The FEHBlog was disappointed that OPM Director Pon was unable to attend because of flight problems. The conference was interesting. The FEHBlog already covered the many of the highlights over the past few months. Here’s some stuff that the FEHBlog missed:

• The keynote speaker from the National Business Group on Health mentioned a new benefit design approach called Bind that’s growing popularity.
• OPM’s medical director mentioned the President’s initiative to address the opioid crisis.  The U.S. Surgeon General by videotape reminded the attendees that “Everyone has a role to play in this crisis. Addiction
  requires a coordinated response.” 

On Thursday, a bipartisan group of Senators introduced a 2018 postal reform bill (S. 2629).  While the bill’s text is not yet publicly available, Govexec.com reports that the bill “largely mirrors” the House bipartisan 2017 Postal reform bill (HR 756) which the House Oversight and Government Reform Committee unanimously approved last Spring.

The bill’s sponsors invoked a rule on Thursday—the same day the bill was introduced—to allow the measure to skip the normal committee process and head straight to the floor for a vote. The timing of such a vote remains unclear.

As previously discussed here, these Postal reform bills would create a new Postal Service Health Benefits Program within the FEHBP. The PSHBP plans would only be open to Postal Service employees and annuitants. The law would require full integration with Medicare Parts A, B, and D for annuitants. That requirement in turn would lower premiums for everyone. The third bounce of the ball is that those savings would redound to the benefit of enrollees and the Postal Service which would see its FEHBP pre-funding for retirees obligation decrease.

The Postal Service reform bill is important to the America economy because, among other reasons, there are large geographic swaths of the country with no deliver service other than the Postal Service.  It’s not surprising therefore to see the Postal Service, the Postal Service labor unions, and customers coalesce around this bill which has been a long time coming.

The FEHBlog has been attending the FEHBP Carrier Conference.  He learned that OPM’s medical liability reform legislative proposal which the FEHBlog discussed in a post last Saturday reflects a Trump Administration proposal to make nationwide changes to state medical malpractice laws. The initiative is not limited to the FEHBP. This makes more sense. The FEHBlog will be providing more observations from the conference over the weekend.

Also according to the Hill, Congress last night approved the $1.3 trillion omnibus spending bill. The President is expected to sign it today.

The House Appropriations Committee site has posted information on the FY 2018 Omnibus Appropriations bill, which has bipartisan Congressional and White House support. Here’s a link to the text of the Financial Services appropriations section of the bill which includes FEHBP related appropriations.  The FEHBlog has confirmed that the bill includes the three traditional FEHBP appropriations measures — the abortion coverage restriction (Secs 613 and 614), the contraceptive coverage mandate (Sec. 726) and the prohibition against applying the Federal Acquisition Regulation’s cost accounting standards to FEHBP contracts (Sec. 611).

Congress is making progress toward an omnibus spending bill for the current fiscal year, according to the Hill. The deadline is Friday, March 22.

The FEHBlog ran across an excellent op-ed written by a couple of physicians explaining why your doctor’s computer is so “clunky.” Hint: as the FEHBlog has pointed out the problem lies with the $37 billion dollar electronic medical record giveaway in the 2009 stimulus law. The author’s recommendation?

In announcing the [recent] Trump-administration initiative, White House aide Jared Kushner and Seema Verna, administrator of the Centers for Medicare and Medicaid Services, said health-technology companies, insurers, doctors, hospitals and patient groups have been working together for six months on an initiative called MyHealthEData to modernize EHRs and achieve interoperability. But the usual suspects can only do so much. This is a market begging for competition from the likes of Amazon, whose cost-cutting and ease-of-use expertise is well established. Apple has also made a welcome entrance into the market. The administration can help by directing HHS to allow EHR competition.

Healthcare Dive reports on a Fair Health survey that not surprisingly finds that “Private insurance claim lines for services rendered in urgent care centers grew 1,725% between 2007 and 2016. That was well above the growth rate of 229% for emergency room (ER) claims during the same period.” After all, if you build it, they will come. The report does indicate that prices are lower in the urgent care centers as compared to the hospital emergency rooms.

Modern Healthcare informs us that a shortage in injectable opioids is threatening patient care due to a manufaturing problem at a Pfizer factory.

Other companies can’t make up the difference because they don’t have the capacity. Even if they did, the Drug Enforcement Administration is unwilling to give them large amounts of raw materials. The DEA implements annual caps on the amount of raw material a manufacturer can use to make opioids—one mechanism it has to try to limit the diversion of the addictive drugs amid the addiction epidemic.  

The DEA has not shifted those caps to allow other manufacturers to produce enough to offset the shortage of injectable narcotics, according to Premier, which has advocated for the agency to loosen its quota restrictions. 

Ruh roh.

Health Day informs us that the flu season is finally subsiding.

To no one’s surprise, Healthcare Dive reports that hospital prices are shooting up. “Annual hospital price growth rose sharply to 3.8% — its highest pace since November 2009.”

Again to no one’s surprise, Med Page Today tells us about a new American Medical Association survey which finds that doctors detest insurer pre-authorization for services that they recommend or prescribe. The author , who is an MD, makes a good point in his conclusion:

If insurers really just want to make sure that care is appropriate, make it easy for us to prove that the care is appropriate – integrate prior authorization into the electronic medical record, make it fast, and give results before the patients leave our offices.

OPM and the Defense Department announced yesterday that

the Federal Employees Dental and Vision Insurance Program (FEDVIP) will be offered for the first time to TRICARE eligible retirees and their families during the 2018 Federal Benefits Open Season. Active duty family members will be eligible to enroll in FEDVIP vision insurance.

The TRICARE Retiree Dental Program ends on Dec. 31, 2018. Those enrolled in TRDP must choose a dental plan through FEDVIP to have coverage in 2019. Enrollment is not automatic. Today’s announcement affects 1.63 million beneficiaries enrolled in TRDP and offers a choice to an additional 1.3 million eligible retired beneficiaries not currently enrolled in TRDP. 

Given OPM’s recent interest in medical liability report, it’s worth noting this Med Page Today article about the root cause of many malpractice claims — misdiagnosis.

Study author Robert Hanscom, vice president of business analytics at Coverys, spoke about the findings. The following is a lightly edited transcript. 

Q: What leapt out at you with your findings? 

Hanscom: Clearly we don’t know enough about diagnostic error, which is often hidden from the view of physicians and other providers. Generally, when we see them in malpractice they are missed and delayed cancer diagnoses that would miss any adverse event reporting system, which is often the way that providers learn about mistakes. These are non-events that actually take providers by surprise sometime later down the road.
There is not a lot of intelligence out there, in terms of helping physicians understand where their vulnerabilities are with respect to these errors. 

This is another explanation for the fact that medicine remains as much an art as a science.

Congress remains in session on Capitol Hill this coming week. The continuing resolution funding the federal government runs out on Friday, March 23.  The Wall Street Journal is reporting that a leadership omnibus bill will be released tomorrow. The FEHBlog expects another continuing resolution rather than an omnibus appropriations bill this week. Here’s a link to the Week in Congress’s report on last week’s actions on Capitol Hill.

The week’s highlight is the OPM / AHIP FEHBP carrier conference in Arlington, Virginia. The FEHBlog was pleased to see that the new OPM Director Dr. Jeff Pon on the first day’s agenda. The day and half conference will be held on Thursday March 22 and Friday March 23.

As promised, here’s the FEHBlog’s take:

1. Medical liability — OPM wants to make a number of reforms to medical malpractice litigation affecting FEHBP members, e.g., capping non-economic damages to $250,000. First off, medical malpractice litigation cases typically are heard in state courts.  This proposal strikes the FEHBlog as being outside OPM’s authority. In any event, the FEHBP has eight million members while the U.S. population is 325 million. The FEHBlog can’t imagine that these changes would have an impact on medical malpractice insurance premiums or defensive medicine. How would the doctor know that he had a looser leash because the patient is covered under the FEHBP?

2. Modify the government contribution based on plan performance — From the inception of the program in 1960 until 1997, the government contribution toward FEHBP coverage was based on the so-called Big Six formula. The government contribution was 60% of the average premium taking into account the two government wide plans (Blue Cross and at the time Aetna), the two largest employee organization plans, and the two largest HMOs participating in the FEHBP (usually the California Kaisers).  The government contribution was capped at 75% of the selected plan’s premium.  In 1990, Aetna terminated its government wide indemnity benefit plan. Congress provided an Aetna fix to the Big Six formula — a “phantom” Aetna rate was included in the formula. In 1996 for 1997, Congress replaced the Big Six formula with the so-called Fair Share formula.  The Fair Share formula sets the government contribution at 72% of the enrollment weighted average premium capped at 75% of the selected plan’s premium. OPM is proposed to set the government contribution at 70% of the enrollment weighted contribution. The employee will continue to pay at least 25% of the selected plan’s contribution. OPM will give each plan up to five additional percentage points for a good plan performance assessment score or subtract up to five additional percentage points based on a poor plan performance assessment.  The FEHBlog is not a fan of the plan performance assessment. Leaving that aside, assuming for the sake of argument that this proposal actually will save the government money, OPM should allow for raise the 75% cap to 77% or even higher.  Otherwise the plans with lower premiums and higher plan performance scores will be hurt as they already are at a 75% government contribution.

3.  Incorporate portions of the federal health programs anti-kickback act into the FEHBP — This is an Inspector General objective which would be very disruptive to the FEHBP if adopted by Congress as the FEHBlog has previously explained. The anti-kickback act is designed to prevent providers from screwing around with government set pricing for Medicare, Medicaid and Tricare. FEHBP carriers negotiate their pricing with providers contractually. For that reason, Congress exempted the FEHBP from this law in 1996 when it applied this Medicare law to Medicaid, Tricare, and certain other federal healthcare programs. The FEHBP is not a public program. The FEHBP is employer sponsored healthcare / commercial program. Similarly, in 2013 the Departments of Health and Human Services exempted the qualified health plans participating in the Affordable Care Act marketplaces. The FEHBlog could go on at greater length. This very bad idea would create a ton of work for lawyers. OPM should move the FEHBP toward the commercial marketplace not toward Tricare.

4. Modify the government wide indemnity benefit plan definition — The government wide indemnity benefit plan slot in the FEHBP has been vacant for over 25 years. OPM now wants to modify the definition such that the insurer filling the slot does not have be licensed in all States and the District of Columbia, which is a surprisingly high bar currently. However, in the FEHBlog’s view, the slot has remained vacant because OPM requires the government wide carriers to use an archaic financing method as required by the 1959 statute. OPM should ask Congress to be given authority to adopt a financing mechanism that is commercially appropriate for 2018. That might attract a new carrier.

Thanks to this Fedweek article, the FEHBlog realized that OPM had made public a justification to Congress for its budget proposal including its related legislative proposals. The discussion of OPM’s legislative proposals for our beloved FEHBP begin on page 21. The FEHBlog will discuss his concerns about those proposals over the weekend.