FEHBlog

Avalere Health posted a report on the anticipated negative impact of the Trump Administration’s association health plan rule on the ACA individual marketplace. Bear in mind that the association health plan rule would allow small employers to return to same employer sponsored marketplace that they used before full Obamacare kicked in. More flexibility, more choice, lower cost. The FEHBlog has an idea — let the large marketplace rules apply across the board.

Yesterday, as NPR reports, the White House held a summit on the opioid crisis. “After introducing a personal friend who lost a son to drugs, the president addressed his administration’s plans for battling the opioid epidemic. ‘The administration is going to be rolling out policy over the next three weeks, and it will be very, very strong,’ Trump said. I’ve also spoken with [Attorney General] Jeff [Sessions] about bringing a lawsuit against some of these opioid companies.'”

Uber, the ride sharing company, introduced Uber Health which allows healthcare providers to arrange rides for their patients in order to reduce no-shows, among other things. Healthcare Dive considers four questions raised by the initiative. The FEHBlog wonders whether health benefit plans will use Uber Health to help get members to healthcare visits in order to boost their HEDIS health care quality measure scores.

Becker’s Hospital Review sent a chill up the FEHBlog’s spine by reporting that the World Health Organization will be releasing the ICD-11 diagnosis coding set in June 2018. “The latest draft version contains about 30 main categories. New categories include conditions related to sexual health, traditional medicine conditions and diseases of the immune system. The traditional medicine chapter involves ‘disorders and patterns which originated in ancient Chinese medicine and are commonly used in China, Japan, Korea, and elsewhere around the world.'” Will our government have the gumption to say no to replacing the already complicated ICD-10 with the ICD-11 for HIPAA coding set purposes?

Govexec.com had an FEHBP related article yesterday concerning a dispute between the OPM Inspector General and an FEHBP carrier that sponsors an HMO plan covering about 4,000 people in California The carrier Health Net is part of a much larger Fortune 500 company Centene. The company balked at the scope of the Inspector General’s information security audit. However, the audit goes beyond a normal audit because the Inspector General wants to conduct its own vulnerability testing on Centene’s system. Vulnerability scans check on whether the software is up to date, among other things. The contract clause quoted in the Inspector General’s report allows OPM to make security recommendations to carriers based on the Government’s FISMA rules (NIST Special Publication 800-53). Rather than conduct its own vulnerability test, why not explain how it would conduct the test and recommend that the carrier use the same approach. That approach is consistent with the contract but much less intrusive. OPM should not be driving carriers away from the FEHBP.

Following up on yesterday’s post, Healthcare Dive reports that CVS Health and Aetna came out of yesterday’s Congressional hearing on their combination unscathed. The article points out that the American Medical Association raised questions about but did not expressly oppose the merger.

Two steps were taken yesterday on the opioid crisis front.  CNBC tells us that the Justice Department announced the creation of a new task force to pursue the parties that contributed to the opioid crisis, both in civil and criminal courts.  According to the Hill, a bipartisan group of Senators have submitted a bill that “includes a host of policy changes, such as establishing a three-day initial prescribing limit on opioids for acute pain, beefing up services to promote recovery and aiming to increase the availability of treatment.” The House is preparing its own legislation directed at the opioid crisis. A bill could be produced before the August recess.

Speaking of legislation, the Congressional Budget Office released a report today giving the green light to Sen. Ron Johnson’s bill (S. 2221) to repeal the ACA’s multi-state program which OPM has been running.

Beckers Hospital Review announced the release of Healthgrades’ 2018 list of best U.S. hospitals. The list, however, does not include many big city tertiary care hospitals, such as those in Boston, New York, Chicago, and Washington, DC.

Mhealth Intelligence reports that

Libertana Home Health, one of California’s largest home health providers, deployed Echo Dot devices programmed with Amazon Alexa at five independent living units in Valencia last year. Running on the Orbita Voice software platform, Alexa can summon a Libertana app that enables users to check their daily schedule, connect with caregivers, schedule appointments, plays games or music and even be reminded about medications and health tasks. All by simply calling out to Alexa.

What’s next?

The Wall Street Journal published a fascinating story yesterday on the future of hospitals.

The days of the hospital as we know it may be numbered.  In a shift away from their traditional inpatient facilities, health-care providers are investing in outpatient clinics, same-day surgery centers, free-standing emergency rooms and microhospitals, which offer as few as eight beds for overnight stays. They are setting up programs that monitor people 24/7 in their own homes. And they are turning to digital technology to treat and keep tabs on patients remotely from a high-tech hub.

Cost curve down perhaps??

Today, a House Judiciary subcommittee held a hearing on the CVS – Aetna combination.  The FEHBlog listened to the first 30 minutes of the hearing. Interesting exchanges. Beckers Hospital Review reports that Aetna’s CEO Mark Bertolini observed on CBS yesterday that

CVS Health comprises 10,000-plus clinics and pharmacies across the U.S., which Mr. Bertolini said will act as “10,000 new front doors to the healthcare system.” These spaces could become local options for preventive care, filling prescriptions and treatment, which may sway Americans from entering the healthcare system only when they’re in need of extensive care, he added.

Of course, the CVS Pharmacies and their Minute Clinics already serve these purposes. It will be interesting to see what Aetna adds to the mix. The FEHBlog has long thought that insurers can improve their public standing through face to face contact. The greatest advantage likely will arise from tighter combination of data.

Drug Channels came out with its latest economic report on U.S. pharmacies and pharmacy benefit managers.

“The U.S. drug channel has become increasingly consolidated,” says Drug Channels Institute CEO Adam J. Fein, Ph.D., the study’s author and a widely regarded expert on pharmaceutical economics and the drug distribution system. “Six companies—CVS Health, Walgreens Boots Alliance, Express Scripts, Walmart, Rite Aid, and UnitedHealth—accounted for almost two-thirds of U.S. prescription dispensing revenues in 2017. Also, more than 70% of equivalent prescription claims are processed by three PBMs: the Caremark business of CVS Health, Express Scripts, and the OptumRx business of UnitedHealth.”

Congress returns to work on Capitol Hill this week following a district work week for President’s Day.

The Wall Street Journal reports that the FDA is putting pressure on the prescription drug manufactures to develop a more effective, quick flu diagnostic tool. The existing tools have high level of false negatives.

New diagnostics are starting to become available. Earlier this month, the FDA cleared Quidel Corp.’s QuickVue Influenza A+B test, the company said. Abbott Laboratories ’ Alere unit and Becton, Dickinson & Co. also say they have antigen-based tests that meet the raised standards. Some companies have also introduced another rapid flu diagnostic they say is more accurate: molecular-based tests, which detect viral nucleic acid in patient specimens.

Avik Roy in Forbes magazine’s Apothecary column writes about the Trump Administration’s decision to expand the availability of shore term insurance coverage:

Prior to 2016, because of the high cost of Obamacare-regulated plans, a growing number of individuals had been turning to a more affordable alternative: short-term, limited-duration plans that are exempt from most Obamacare regulations. These plans could last up to 364 days, and be renewed, before the Obama administration cracked down in mid-2016 and limited their duration to three months.
The National Association of Insurance Commissioners wrote a blistering letter arguing that the Obama crackdown was misguided, because “it could harm some consumers, limit consumer options, and have little positive impact on the risk pools in the long run.”
In response to these concerns, the Trump administration has now proposed new rules under which these affordable STDLI plans would once again be available to those who want them, for up to 364 days. “While in the past these plans were a bridge, now they can be a lifeline,” says Seema Verma, chief of the Centers for Medicare and Medicaid Services. 

The FEHBlog agrees that it helps consumers to give more choice in coverage.

Finally, Health Payer Intelligence reports that payers are making progress toward electronically pre-authorizing medical and pharmacy services. 

Providers that exclusively used an electronic prior authorization for
medication requests reduced their administrative workload by 2.5 hours
each week. However, only 24 percent of providers exclusively used an
electronic prior authorization solution and the remaining 76 percent
used multiple, complex prior authorization channels.

For the past year now, the FEHBlog has enjoyed working with a health care quality consulting group called Discern Health.  The FEHBlog ran across this recent Discern paper on integrating social care with health care in order to achieve better population health. The paper considers how accountable care organizations seek to share risk with healthcare providers and community based organizations that deliver food, etc.. The ACO uses the community based organizations to check blood pressure and so on. It’s an interesting idea.

In the course of his work today, the FEHBlog ran across this recent study of well being in the U.S.  The study provides state by state wellbeing rankings.

Although improvements in certain physical health categories and community well-being signal progress, the sharp declines in overall well-being were driven by drops in purpose and social well-being metrics, as well as the mental health aspects of physical well-being. Out of a possible score of 100, the national Well-Being Index score dropped from 62.1 in 2016 to 61.5 in 2017, marking the largest year-over-year decline since the index began in 2008.

South Dakota, Vermont, and Hawaii are 1, 2, and 3 in terms of well-being.

The Wall Street Journal reports today that the awful flu season apparently has peaked (CDC issues flu reports weekly during the flu season). However, “transmission is still intense, and cases from a strain that often surges late in the season are rising. ‘The amount of activity is still very high,’ Daniel Jernigan, director of the flu division at the Centers for Disease Control and Prevention, which released the data, said in an interview. ‘There are still many weeks left of this flu season—probably through mid-April.’” Stay warm and hydrated this weekend.

The President’s Council of Economic Advisers issued its 2018 report this week.  Public health issues are covered from pages 279-321.  The report provides a useful perspective on major public health issues that concern OPM — opioids, obesity, and tobacco use.  The opioid discussion raises a point (p. 293) that the FEHBlog noted last month when discussed Sam Quinones’ excellent book Dreamland.

The opioid epidemic evolved with three successive waves of rising deaths due to different types of opioids, with each wave building on the earlier one (Ciccarone 2017). In the late 1990s, in response to claims that pain was under- treated and assurances from manufacturers that new opioid formulations were safe, the number of opioid prescriptions skyrocketed (CDC 2017b). What followed was an increase in the misuse of and deaths related to these prescriptions (figure 6-2). As providers became aware of the abuse potential and addictive nature of these drugs, prescription rates fell, after peaking in 2011. Deaths involving prescription opioids leveled off, but were followed by a rise in deaths from illicit opioids: heroin and fentanyl. Heroin deaths rose first, followed by a rise in deaths involving fentanyl—a synthetic opioid that is 30 to 50 times more potent than heroin and has legitimate medical uses but is increasingly being illicitly produced abroad (primarily in Mexico and China) and distributed in the U.S., alone or mixed with heroin. In 2015, males age 25 to 44 (a core group of the prime-age workers whose ages range from 25 to 54) had the highest heroin death rate, 13 per 100,000. Fentanyl-related deaths surpassed other opioid- related deaths in 2016. 

Emphasis added. Very sad. The government should have placed more focus on this issue years ago.

The Wall Street Journal reports that the new budget law will require high earning seniors to pay more for their Medicare coverage.

Starting in 2019, individuals with incomes of $500,000 or more and couples earning $750,000 or more will be broken out of the current top bracket and required to pay 85% of the cost of their Medicare parts B and D benefits, up from 80% now. (In contrast, Medicare beneficiaries with incomes of $85,000 or less—or $170,000 or less for couples—pay only 25% of the cost of their benefits.) 

For higher-income beneficiaries, this increased premium surcharge comes on the heels of a separate increase that went into effect on Jan. 1. Under that increase, Medicare beneficiaries with incomes of $133,501 to $160,000 (or $267,001 to $320,000 for couples) now must pay 65% of the cost of their parts B and D benefits, up from 50% before Jan 1. And beneficiaries with incomes between $160,001 and $214,000 (or $320,001 and $428,000 for couples) were shifted from a 65% surcharge into the highest income group that currently pays 80% of the cost of their benefits.

Higher Medicare Part B premiums discourage Medicare eligible federal annuitants from picking up Medicare Part B. Granted federal annuitants typically don’t fall into these income levels. The problem as the FEHBlog sees it is that the income levels in the second paragraph might encompass a cadre of  federal annuitants in the early years of retirement. If you don’t pick up Medicare Part B promptly following retirement, you will be penalized for late enrollment. (That’s the approach that the ACA should have used.)

The article also points out that

The [budget] law also closes the Medicare Part D coverage gap, known as the doughnut hole, in 2019—one year sooner than planned. Part D prescription drug plans typically cover 75% of the cost of medication, leaving the participant to pick up 25%. But after the total cost of a participant’s drugs reaches a set amount per year—$3,750 in 2018—he or she falls into the doughnut hole. Once there, the participant is currently on the hook for 35% of the cost of his or her brand-name medications, up to $5,000 in total out-of-pocket costs, said Ms. [Juliette] Cubanski [, an associate director of the Henry J. Kaiser Family Foundation’s program on Medicare policy].  At that point, catastrophic coverage kicks in, limiting participants’ outlays, typically to 5%. Next year, when the doughnut hole disappears, Part D beneficiaries will pay 25% of their total costs until the catastrophic coverage kicks-in. 

This really frosts the FEHBlog’s cake because OPM does not permit FEHB plans to integrate their prescription drug benefits with Medicare Part D prescription drug plan coverage through an employer group waiver plan even though the Medicare law expressly permits FEHB plans to take this step. EGWPs would lower the cost curve for FEHB plans which is why the Postal Service wants them in the Postal Service Health Plans contemplated by the postal reform law (HR 756).

Finally, in an article that the FEHBlog finds uplifting, plansponsor.com tells us that

ConnectYourCare’s 2018 report on consumer-driven health care account trends finds 44.9% of respondents chose to enroll in a health savings account (HSA) as a savings vehicle for future health care needs, over more immediate benefits like tax savings and lower premiums, up from 40.5% in its 2017 report. 

The majority of HSA account holders are spenders, both by their self-evaluation and backed up by spending and balance data. However, 44% of account holders saved at least half of their contributions in 2017, which may indicate a future shift in saver/spender trends. 

Twenty-two percent of respondents overall say that paying for health care in retirement is the health care issue that concerns them most. However, when segmented by age, this rises to the top issue causing concern for those ages 55 to 64 (37.4%) and those age 65 and older (30.9%). Those younger than 25 are most concerned about unanticipated health care expenses and those ages 25 to 54 are most concerned about increasing insurance premiums.

The FEHBlog started out as an HSA spender but now is an HSA saver while he can still contribute. Your ability to contribute to an HSA cuts off when you start to receive Medicare. You can delay Medicare coverage beyond age 65 if you are still working. Here’s a handy CMS worksheet. For most employers, including the federal government, the employer sponsored coverage remains primary to Medicare past age 65 until retirement. However, in the FEHBlog’s case, his business has less than 20 employees, so Medicare will be his primary coverage when he turns 65.  The health insurance savings from switching to Medicare outweigh the value of the additional HSA contributions that the FEHBlog could have made by delaying Medicare. But he can spend the HSA account funds past age 65 tax free on medical expenses including Part B premiums.  

A newly proposed FEHB rule will be published in tomorrow’s Federal Register. The rule concerns an anchronism in the FEHB Act that requires carriers to offer conversion coverage. The provision made sense when there was no ACA marketplace. Since 2014, replacement coverage has been readily available in the ACA marketplace, and the insurers that previously offered conversion coverage backed out of the market. Rather than simply ask Congress to repeal the requirement expressly, OPM has modified the requirements to integrate the conversion requirements with the ACA marketplace. The rule formalizes these modifications.  The proposed rule will be open to public comment for sixty days.

Today the ACA regulators from the Trump Administration proposed a new ACA rule that will permit insurers to offer short term health insurance coverage for up to 12 months. The ACA regulators under the Obama Administration had cut back on that coverage to a maximum of three months purportedly in order to protect the ACA marketplace.

If Congress in 2010 really had wanted to funnel people into the exchanges, it would have cut back eligible child coverage from 26 to 22 and eliminated COBRA and FEHB TCC continuation coverage and patchwork coverage effective for 2014.  Continuation coverage requirements generate losses for employer sponsored plans due to adverse selection. Congress also would given people in the marketplace more choice of coverage rather than dictate the scope of coverage. But that’s not where we are right now.

In other news, Albertson’s, a privately held grocery store chain that also operates under 17 brand names including Safeway, Von’s and Osco-Jewel brands, is buying the roughly 2,000 Rite Aid Stores that fell outside the Rite Aid’s previous deal with the Walgreen’s Boots Alliance.  The Wall Street Journal observes that

All three of the U.S.’s biggest pharmacy chains are now pursuing deals in a sign of the threats they face as customers increasingly shop online. CVS has agreed to buy health insurer Aetna Inc., and Walgreens, in addition to the scaled-back Rite Aid deal, is in talks to buy drug distributor AmerisourceBergen Corp. , The Wall Street Journal recently reported.

The Albertson’s deal which is subject to regulatory approval is expected to close in the third quarter of this year.

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

Following up on a couple of last week’s posts, the FEHBlog noticed an op-ed today in which the author complained that he had to bring a lawsuit against his insurer in order to correct a prior authorization decision. This isn’t the case. Patient Advocate explains that ACA marketplace plan members can appeal prior authorization decisions and obtain an independent review organization decision that is binding on the insurer. Why don’t people understand this when insurers are obligated to place members on notice of appeal rights. The fixable problem as the FEHBlog see it is that while member of employer sponsored plans, including the FEHBP where OPM acts as the independent reviewer, must exhaust their administrative remedies unless the insurer screws up procedurally, ACA marketplace members can choose between a lawsuit and independent review. Litigators are likely to choose the lawsuit route for their clients. Congress should align the individual marketplace with the employer sponsored plan marketplace as far as it concerns exhaustion of an available administrative remedy. That would lower costs for everyone.

The Wall Street Journal has a report this afternoon about the number one hospital caused infection. That infection surprisingly to the FEHBlog at least is pneumonia, which my father call the “Old Man’s Friend,” not sepsis.

Hospital-acquired pneumonia is more pervasive and urgent than most people realize, a new study warns, and hospitals in America aren’t adequately addressing prevention. “Given the mortality, hospitals should be doing a lot more,” says Dian Baker, lead author of the study, which was published in January in the American Journal of Infection Control.

Pneumonia, which typically comes from germs that enter the body through the mouth, is the No. 1 hospital-acquired infection in America, according to the Centers for Disease Control and Prevention. That includes both pneumonia infections that some patients on ventilators catch from bacteria in their breathing tubes as well as the more common non-ventilator variety, the CDC says.

According to the article, NYU Langone Medical Center is requiring that patients who are about to undergo surgery brush their teeth. This has proven to be an effective technique to help stop the spread of pneumonia.

Finally Multibriefs.com reports that

Healthcare data breaches continued to rise in 2017, but the number of affected patient records declined 80 percent, a new report suggests. According to the Protenus Breach Barometer, 2017 may have simply been an off year for malicious actors, who may be regrouping for more attacks in 2018. [Let’s hope not.]

A total of 477 data breaches were reported to the Department of Health and Human Services’ Office for Civil Rights during the year, up from the 450 reported in 2016. However, the positive news for healthcare organizations and leaders is that fewer records were implicated in the breaches, specifically, 5.6 million in 2017 versus 27.3 million in 2016.

Ah, it’s the beginning of the last federal three day weekend that in turn launches the great federal holiday drought. No more three day weekends until Memorial Day.

The FEHBlog has been reflecting on Sen. Claire McCaskill’s opening comments at the Senate Homeland Security and Governmental Affairs Committee’s business meeting last Wednesday. Sen. McCaskill (D Missouri) is the ranking minority member on the Committee. She bemoaned the fact that the Committee was about to kill the ACA’s multi-state program rather than try to fix it.  The multi-state program was an OPM-administered program intended to cover the state based exchanges with commonly designed plans. One of the many problems with the multi-state program was the fact that the participating plans were subject to both OPM and state regulation. Blue Cross tried to help out OPM, but the Blue Cross multi state plans were competing with the local Blues plans in the exchanges. In other words, like many parts of this law, the multi-state program was overkill, and repeal is the proper outcome.

OPM’s administration of the multi-state program has unfortunate effects for the FEHBP. As the FEHBlog has mentioned, the large group market in which the FEHB sits has the loosest ACA restrictions while the multi-state program was in the individual market which has the tightest ACA restrictions. The multi-state program allowed OPM to learn about those tighter restrictions and apply them to the FEHBP. Cost curve up.

The point is that Sen. McCaskill should recognize that in many respects the ACA overreached and the best fix is to trim it back.

In a bit of good news, yesterday the Food and Drug Administration approved a blood test for concussions. The results are available in three to four hours. The New York Times reports that

The test, called the Banyan Brain Trauma Indicator, is also expected to reduce the number of people exposed to radiation through CT scans, or computed tomography scans, that detect brain tissue damage or intracranial lesions. If the blood test is adopted widely, it could eliminate the need for CT scans in at least a third of those with suspected brain injuries, the agency predicted.

Well done.