FEHBlog

The FEHBlog made a mistake in several posts about the current continuing resolution. He thought that the additional health insurer tax moratorium applies to this year. In fact, this moratorium applies to 2019. So the government will be collecting $14.3 billion from insurers this year which Congress evidently assumes was already baked in the premiums. Here’s a link to the IRS guidance on the 2019 moratorium.

Congress is in session this week on Capitol Hill.  The FEHBlog’s attention was drawn to a Hill newspaper article headlined “Congress takes the sting out of Obamacare.”  In the FEHBlog’s view, Congress started to take the sting out of the law by repealing the individual mandate but it has a long way to go still. Way too much stick and not enough carrot in that law.

For example, the FEHBlog pointed out a few weeks ago a December 2017 HHS report on 2016 medical loss ratio (“MLR) results.  The HHS report notes that “In 2016, the average MLR was 92.9 percent in the individual market, 86.1 percent in the small group market, and 90.3 percent in the large group market.”  The statutory MLR is 80% for the individual and small group markets and 85% for the large group market which includes the FEHBP. So you would think that the MLR rebates would have been small in 2016, but they totalled hundreds of millions of dollars because those refunds are determined using state-level MLRs for each insurer.

FEHBP insurers are in double jeopardy because they are subject to this state-level MLR and OPM’s contract level MLR. It’s no wonder that you don’t see new carriers joining the FEHBP.  In any event, all MLR penalties / rebates should be based on the insurer’s aggregate MLR per market with no state or contract breakdown.

Health Payer Intelligence points out a recent AMA report finding that the ACA reduced consumer out of pocket spending by 11.9% but increased consumer spending on health insurance premiums by 12.1% over the period 2012-2015. There has to be a better, less complex, way. The FEHBlog continues to like his idea of giving all high earners, not just small business owners, a 50% tax exclusion on health insurance premiums. Give all middle income people, not just employees, a full exclusion and repeal the ACA taxes on providers and health plans. The low income people would continue to have ACA subsidies. That would be a good, equitable start.

In prescription drug news, Wired has an interesting report on the state of CRISPR gene editing research.

[Last] week the National Institutes of Health announced it will be awarding $190 million in research grants over the next six years, in part to push gene editing technologies into the mainstream. “The focus of the Somatic Cell Genome Editing program is to dramatically accelerate the translation of these technologies to the clinic for treatment of as many genetic diseases as possible,” NIH Director Francis Collins said in a statement Tuesday. Which could encourage some of the more exotic, experimental delivery systems out in the research world—strategies like Crispr-covered gold beads, yarn-like ball structures called DNA nanoclews, and shape-shifting polymers to get the editor where it needs to go.

Let’s go.  Also, the Wall Street Journal yesterday offered a fascinating interview with  economist David Ridley.  Prof. Ridley came up with idea of having the Food and Drug Administrative give drugs that treat rare diseases an express lane pass for a future new drug application. What’s more the express lane pass can be sold to another drug manufacturer for “between $67.5 million and $350 million, though the price last year settled in the range of $125 million to $150 million.” The applicant must pay a $2.7 million fee to use the express lane. Congress enacted the idea in 2007. At the first the express lane pass was awarded for infectious tropical disease treatments, and in 2012 the initiative was extended to rare pediatric diseases. Last year, the FDA issued “five [passes or more formally expedited review vouchers] for drugs to treat rare pediatric diseases and one for the tropical Chagas parasite, which afflicts more than six million people world-wide.” Cool.

It continues to be a busy week.  As Healthcare Dives reports, the Senate confirmed Alex Azar to be Secretary of the Health and Human Services Department. Meanwhile, the President’s nominations to be OPM Director and OPM Deputy Director continue to cool their heels due to Sen. Ron Johnson’s hold. The FEHBlog can find no news about the status of those nominations. Mysterious and unfortunate in the FEHBlog’s view.

The FEHBlog recalls that about five years ago OPM was pushing a government initiative called Blue Button which would allow you to download your claims history into a spreadsheet. The initiative lost steam according to this government website. Never fear. Apple plans to permit hospitals and other healthcare providers to download your electronic medical record (more likely keys parts of it) into your phone. Becker’s Hospital Review discusses the Apple initiative which makes a lot of sense.

On the opioid crisis front, the Federal Trade Commission and HHS’s SAMHSA unit released a consumer factsheet yesterday with tips on how get the right help of opioid addiction.  Meanwhile and disturbingly, Beckers Hospital Review reports that

United States residents purchased nearly $800 million worth of fentanyl pills from China over the internet in two years [and delivered by the Postal Service], according to a Senate investigations report released Wednesday. The 104-page bipartisan report produced by the Senate Homeland Security Committee is the result of a yearlong Senate investigation.

Fentanyl is a dangerous synthetic opioid that you can’t just pick up at CVS. The report explains that

Commercial shippers like UPS and FedEx are required to provide U.S. Customs and Border Protection with information about the origin and contents of the packages prior to their arrival. However, customs officials do not receive information on all packages shipped through the United States Postal Service. The volume of shipments and the limited information made available from certain foreign postal services make identifying packages containing illicit drugs difficult.

Loopholes as W.C. Fields remarked.  Opioid distribution, e.g., heroin, fentanyl, has returned to being principally a law enforcement issue. The fallout from opioids remains a key concern for providers and payers, in the FEHBlog’s view.

The U.S. Office of Personnel Management this morning issued its call letter for 2019 benefit and rate proposals.  The call letter describes the laundry list of initiatives that it wants the FEHB plans to cover in their 2019 benefit and rate proposals due May 31, 2018. The letter jumped the gun a little because it emphasizes on page 5 the potential impact of the ACA’s high cost excise or colloquially the Cadillac tax on FEHB plans. Yesterday, Congress delayed the effective date for that tax for two more years. The tax originally was scheduled to take effect this year. Two years ago, Congress delayed the effective date to 2020 and yesterday Congress further delayed the effective date to 2022.

The Cadillac tax is very inequitable to the FEHBP.  The tax assumes the average family size to be 2.7 members but the FEHBP family size is much lower which is why self plus one is popular. Consequently, FEHBP self only premiums tend to already be bumping up the ACA’s self only threshold of $10,200 plus adjustment while the self and family and self plus one rates tend to comfortably below the $27,500 other than self only threshold. OPM’s call letter does not appreciate this nuance.

Consequently, the FEHBlog thinks that it would be helpful for OPM to issue a draft call letter in January and a final call letter in early March. The Centers for Medicare and Medicaid Services take this approach with the Medicare Advantage program.

One of the other laundry list items in the call letter is immunizations. The FEHBlog’s internist told him today that Glaxo Kline has obtained Food and Drug Administration approval for a new shingles vaccine called Shingrix. CNN reports that the government has approved Shringix for adults aged 50 and older, even those like me who had the predecessor shingles vaccine, Zostovax.  Shingrix is two injections two months apart. The FEHBlog’s internist suggested waiting a couple months before approach CVS or another pharmacy for the new vaccine.

Speaking of vaccines, the FEHBlog noticed this essay about the flu in last weekend’s Wall Street Journal.

Despite medical advances, we are just as vulnerable today to a flu pandemic as we were a century ago. Vaccines in recent years have, on average, reduced the risk of flu illness among those vaccinated by just 40% (less than 30% this year). Current antiviral drugs only slow the virus—we have no reliable way to destroy it.

The author’s point was not to discourage people from getting the current flu vaccine. Instead, his point was to place focus on ongoing research to create a universal flu vaccine.  The essayist has some other ideas too.

Also today, the Health Care Cost Institute today came out with a report on health care spending from 2012 to 2016. HCCI maintains a HIPAA de-identified claims warehouse contributed by Aetna, Humana, Kaiser Permanente, and United Healthcare.

“It is time to have a national conversation on the role of price increases in the growth of health care spending,” said Niall Brennan, MPP, president of HCCI. “Despite the progress made in recent years on value-based care, the reality is that working Americans are using less care but paying more for it every year. Rising prices, especially for prescription drugs, surgery, and emergency department visits, have been primary drivers of faster growth in recent years.”

Congress ended the partial federal government shutdown today.  The new continuing resolution (H.R. 195) extends federal appropriations for the federal government through February 8, 2018, extends Children’s Health Insurance Program funding for six years, and suspends the ACA’s health insurer tax for 2018, the ACA’s medical device tax for 2018 and 2019, and further delays implementation of the ACA’s high cost employer sponsored plan excises tax (a/k/a) Cadillac tax from 2020 to 2022.

Also today, the U.S. Office of Personnel Management released a final rule on removal of family members from FEHB plan coverage. The rule concerns voluntary removal of otherwise eligible members and involuntary removal of ineligible individuals with, of course, appropriate due process. The rule will take effect on February 22, 2018.

Well, the FEHBlog never claimed to be all knowing. Federal appropriations did lapse on Saturday because the Senate was unable to achieve 60 votes in favor of debating (cloture) on the continuing resolution. Here’s a link to the Week in Congress’s report on last week’s activities on Capitol Hill.

Because the FEHBP Act, 5 U.S.C. Sec. 8909, creates a 4% surcharge on premiums and a quarter of that surcharge is available for OPM administrative operations, FEHBP operations at OPM are not funded by federal appropriations. So the FEHBP continues to roll on, notwithstanding the shutdown.

Kaiser Health News reports on how the shutdown affects other health programs, like Medicare.

Beneficiaries will be largely unaffected by a shutdown, especially if it is short. Patients will continue to receive their insurance coverage, and Medicare will continue to process reimbursement payments to medical providers. But those checks could be delayed if the shutdown is prolonged.

The Wall Street Journal adds that “There are two services that won’t be disrupted: the mail and the delivery of Social Security checks.”

Federal News Radio reports that the Senate is scheduled to consider a modified continuing resolution funding the federal government through February 8 beginning today at 10 am with a vote scheduled for noon.

Yesterday the House of Representatives passed the continuing resolution discussed in last Wednesday’s post. The ball is bouncing around the Senate’s court. The FEHBP will continue on course even in the unlikely event of a lengthy partial government shutdown. Negotiations are continuing over the weekend according to latest reports.

The Senate Finance Committee voted to advance to the Senate floor the President’s nomination of Alex Azar to be Health and Human Services Secretary last Wednesday according to Fierce Healthcare.

Six relevant healthcare organizations including America’s Health Insurance Plans and the Blue Cross Blue Shield Association as well as major provider groups, have issued a consensus statement intended to streamline situations in which the health plan requires prior authorization for coverage of a particular service or supply.  According to the Consensus Statement, these health care leaders will work together to:

• Reduce the number of health care professionals subject to prior authorization requirements based on their performance, adherence to evidence-based medical practices, or participation in a value-based agreement with the health insurance provider.
• Regularly review the services and medications that require prior authorization and eliminate requirements for therapies that no longer warrant them.
• Improve channels of communications between health insurance providers, health care professionals, and patients to minimize care delays and ensure clarity on prior authorization requirements, rationale, and changes.
• Protect continuity of care for patients who are on an ongoing, active treatment or a stable treatment regimen when there are changes in coverage, health insurance providers or prior authorization requirements.
• Accelerate industry adoption of national electronic standards for prior authorization and improve transparency of formulary information and coverage restrictions at the point-of-care.

Bravo on the collaborative effort to reduce red tape.

Axios reports that “Four not-for-profit hospital systems that own 10% of U.S. hospitals — Intermountain Healthcare, Ascension, SSM Health and Trinity Health — are banding together to create a new generic drug company. The Department of Veterans Affairs also is helping and has expressed interest as a purchaser.”  The FEHBlog noticed a Modern Healthcare article pooh poohing the idea but the FEHBlog applauds these hospitals banded together to try to fix a national problem — bandit drug manufacturer who hike prices on sole source generic drugs. You have to start somewhere.

In the you can’t please ’em all department, Fierce Healthcare reports that

The House bill that would continue funding the federal government from January 19 through February 16, 2018,  fully fund the Children’s Health Insurance Program for six years, and delay the medical device tax for two more years (through 2019), the high-cost employer-sponsored plan excise tax or Cadillac tax also for two more years (through 2021), and the health insurer tax for one more year (through this year). The FEHBlog being a glass half full kind of guy expects this bill to pass.

In a bit of good news, USA Today reports that “Walmart is teaming with a Southern Pines, N.C.. company called DisposeRx, on a solution that consists of a small packet with an FDA-safe chemical blend that, when emptied into a pill bottle with warm water, lets patients dispose of any leftover medications in the trash. The medications — they can be powder, pills, tablets, capsules or liquids — are converted into a non-divertible and biodegradable gel.”  Walmart is giving away DisposeRx for free.  More pharmacy chains should follow their lead as a lot of people have excess Oxycontin in their medicine cabinets.

The FEHBlog noted in last year or two the problems with the Federal Employees Long Term Care Insurance Program.  The Wall Street Journal explains today why the entire long term care insurance market in the U.S. is in “financial turmoil.”

Almost every insurer in the business badly underestimated how many claims would be filed and how long people would draw payments before dying. People are living and keeping their policies much longer than expected. 

After the financial crisis hit, nine years of ultralow interest rates also left insurers with far lower investment returns than they needed to pay those claims. 

Long-term-care insurers barreled into the business even though their actuaries didn’t have a long record of data to draw on when setting prices. Looking back now, some executives say marketing policies on a “level premium” basis also left insurers with a disastrously slim margin of error.

No bueno.

The FEHBlog finished reading Sam Quinones’ 2015 book Dreamland: The True Tale of America’s Opiate Epidemic.  The FEHBlog recommends the prize-winning book to those interested in U.S. healthcare.

Reading the book confirmed for me that while the barn door has been closed on the opioid prescription  crisis (which ran from the mid-1990s when the Food and Drug Administration approved Purdue Pharma’s Oxycontin for marketing until a few years ago when doctors, pharmacists, and state regulators restored sanity) and the large-scale heroin crisis (which depended on the opioid prescription crisis to create new customers), there still is a lot to be done to help people who were harmed during that twenty year period.  The author encourages health plan coverage for multi-disciplinary pain clinics for people suffering from chronic pain (other than cancer patients and mortally ill patients with chronic pain for whom opioid based drugs remain appropriate).

Happy King Day weekend!  Congress continues its work on Capitol Hill this week following the holiday. Here’s a link to the Week in Congress’s report on last week’s Congressional activities.

The Weekend Wall Street Journal which is the FEHBlog’s favorite newspaper published an essay offering “A Cure for Our Fixation on Metrics.” The essay was adapted from Prof. Jerry Z. Muller’s forthcoming book “The Tyranny of Metrics.”  Any reader of the FEHBlog knows that everyone and his brother/sister is trying to measure the quality of healthcare with metrics. Indeed, 65% of an FEHB carrier’s plan performance assessment is based on metrics under OPM’s recent rule. So the Professor’s book is a breath of fresh air to the FEHBlog.

These paragraphs from the essay hit home with the FEHBlog.

The more the object to be measured resembles inanimate matter, the more likely it is to be measurable: that is why measurement is indispensable in the natural sciences and in engineering. When the objects to be measured are influenced by the process of measurement, measurement becomes less reliable. Measurement becomes much less reliable the more its object is human activity, since the objects—people—are self-conscious and are capable of reacting to the process of being measured. The more rewards and punishments are involved, the more people are likely to react in a way that skews the measurement’s validity. * * *

Just because performance measures often have some negative outcomes doesn’t mean that they should be abandoned. They may still be worth using, despite their anticipatable problems. It’s a matter of trade-offs, and that too is a matter of judgment.

With measurement as with everything else, recognizing limits is often the beginning of wisdom. Not all problems are soluble, and even fewer are soluble by metrics. It’s not true, as too many people now believe, that everything can be improved by measurement, or that everything that can be measured can be improved.

If only the healthcare policymakers would take this essay to heart.