FEHBlog

First the FEHBlog wants to point out that he has corrected the erroneous KFF.org link in Monday’s post on Medicare Advantage. Lo siento.

Kaiser Health News kicks off this happy season with a recommendation that family discuss end of life planning during the Thanksgiving dinner. It certainly makes sense to discuss this important issue in a family setting, but Thanksgiving?

In this regard Medical News Today reports  “new [American Cancer Society] research examined a total of 1,570,975 cancer cases, 587,521 of which resulted in death. During the analysis, 26 cancer types and 17 risk factors were analyzed.

These 17 risk factors are called “modifiable” because people can take active measures to change them.”

Health Payer Intelligence discusses how data analytics and employee wellness engagement platforms can improve employee health and reduce health plan costs.

Employers that want increased member engagement for wellness services
such as flu shots or other preventive measures need to capture and
leverage data on their employees’ healthcare conditions, preferred
communication tools, and motivating incentives for utilization.

Leveraging analytics to identify high-risk populations helps
employers determine where to direct communications, and who is most
likely to benefit from services.

OPM certainly is an employer that seeks that type of engagement.

The Hartford Courant reports today that “An acquisition of Aetna Inc. by CVS Health
Corp. may meet little resistance from federal regulators under the
Trump administration, speeding the deal toward completion, two analysts
say. A deal between Aetna and CVS could be announced within days, Dow Jones is reporting.”

Last but not least the FEHBlog overlooked that last Thursday OPM’s Healthcare and Insurance Director Alan Spielman blogged about Open Season. Have a look.

In the course of writing about the ongoing Federal Benefits Open Season, the FEHBlog overlooked linking to this Tammy Flanagan article in govexec.com. Ms. Flanagan also discussed Open Season on a Federal News Radio program last Friday.

Healthcare Dive takes a look at why insurers are flocking to Medicare Advantage.

Payers see MA as a stable market. That’s evident in the fact that MA premiums are expected to decrease by 6% next year. Insurance companies like stability. Insurers increase premiums by double digits when there isn’t stability, which is the case with the ACA exchanges.

KFF.org explains that

Since 2006, Medicare has paid plans under a bidding process. Plans submit “bids” based on estimated costs per enrollee for services covered under Medicare Parts A and B; all bids that meet the necessary requirements are accepted. The bids are compared to benchmark amounts that are set by a formula established in statute and vary by county (or region in the case of regional PPOs). If a plan’s bid is higher than the benchmark, enrollees pay the difference between the benchmark and the bid in the form of a monthly premium, in addition to the Medicare Part B premium. If the bid is lower than the benchmark, the plan and Medicare split the difference between the bid and the benchmark; the plan’s share is known as a “rebate,” which must be used to provide supplemental benefits to enrollees. Payments to plans are then adjusted based on enrollees’ risk profiles [plus some other stuff explained on the KFF.org website] 

FEHBP certainly is stable market but no one is predicting a looming premium decrease. Both MA and FEHBP carriers are subject to a profit limiting 85% medical loss ratio. Under the FEHBP, the government contribution formula works like the MA benchmark but perhaps it’s not as not as efficient as the MA approach. It’s an interesting intellectual exercise.

ICD10 Monitor reports that the American Medical Association has released 2018 changes to its CPT codes and descriptors. HIPAA requires that these CPT codes, which describe outpatient medical services, must be used in HIPAA standard electronic transactions.  The Monitor notes that the 2018 changes amount to 312 edits.

Congress is out of town this week for the Thanksgiving holiday. Here’s a link to The Week in Congress’s account of last week activities.

Following up on last Friday’s posts, here are Fedsmith’s more detailed take on the Medicare Part B premiums and federal annuitant options and the PBM trade association PCMA’s first take on HHS’s proposed 2019 changes to the Medicare Part D program.

We now enter into the second week of the Federal Benefits Open Season. There are twenty two days left to pull the trigger to change plans which is typically only necessary if your current plan has dropped out of FEHBP for 2019. If in doubt check out OPM’s Fast Facts and the Significant Changes list for 2018.

The standard monthly premium for Medicare Part B enrollees will be $134 for 2018, the same amount as in 2017. However, a statutory “hold harmless” provision applies each year to about 70 percent of enrollees. For these enrollees, any increase in Part B premiums must be lower than the increase in their Social Security benefits. After several years of no or very small increases, Social Security benefits will increase by 2.0 percent in 2018 due to the Cost of Living adjustment. Therefore, some beneficiaries who were held harmless against Part B premiums increases in prior years will have a premium increase in 2018.

The 30 percent of all Part B enrollees who are not subject to the “hold harmless” provision will pay the full premium of $134 per month in 2018. Part B enrollees who were held harmless in 2016 and 2017 will see an increase in the monthly Part B premium from the roughly $109, on average, they paid in 2017. An estimated 42 percent of all Part B enrollees are subject to the hold harmless provision in 2018 but will pay the full monthly premium of $134, because the increase in their Social Security benefit will be greater than or equal to an increase in their Part B premiums up to the full 2018 amount. About 28 percent of all Part B enrollees are subject to the hold harmless provision in 2018 and will pay less than the full monthly premium of $134, because the increase in their Social Security benefit will not be large enough to cover the full Part B premium increase.

Medicare Part B enrollees not subject to the “hold harmless” provision include beneficiaries who do not receive Social Security benefits, those who enroll in Part B for the first time in 2018, those who are directly billed for their Part B premium, those who are dually eligible for Medicaid and have their premium paid by state Medicaid agencies, and those who pay an income-related premium. These groups represent approximately 30 percent of total Part B beneficiaries.

The annual deductible for all Medicare Part B beneficiaries will be $183 in 2018, the same annual deductible in 2017. Premiums and deductibles for Medicare Advantage and Medicare Prescription Drug plans are already finalized and are unaffected by this announcement.

The fact sheet includes the table with the rates for higher income Medicare beneficiaries. With respect to Medicare Part A:

The Medicare Part A annual inpatient hospital deductible that beneficiaries pay when admitted to the hospital will be $1,340 per benefit period in 2018, an increase of $24 from $1,316 in 2017. The Part A deductible covers beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. Beneficiaries must pay a coinsurance amount of $335 per day for the 61st through 90th day of a hospitalization ($329 in 2017) in a benefit period and $670 per day for lifetime reserve days ($658 in 2017). For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 of extended care services in a benefit period will be $167.50 in 2018 ($164.50 in 2017).

Quadruple aim?? We all have heard about the healthcare Triple Aim of improving the patient experience of care (including quality and satisfaction); improving the health of populations; and
reducing the per capita cost of health care.  Revcycleintelligence.com suggests that no one will achieve the triple aim without including the fourth aim of provider satisfaction.

Reliant Medical Group [located in central Massachusetts] focuses on the Quadruple Aim by implementing team-based care and placing teams in shared spaces.
The medical group, which includes 27 clinical locations, spreads case workloads across teams of caregivers. The team consists of caregivers of all levels and team members share clinical and bureaucratic responsibilities.
Shared spaces is a key component to Reliant Medical Group’s team-based care approach, [Reliant’s CEO] added.

As the FEHBlog is blue skying, he notes that Modern Healthcare is reporting about the development of new quality measures that go beyond outcomes toward overall health and wellness.

The Institute for Healthcare Improvement recently endorsed what are called “whole system measures,” or a limited number of measures that encompass patient experience, health of populations and costs. The 15 measures assess areas like job satisfaction, social support from family or friends, and ability to afford healthcare services. 

To that end, Health Payer Intelligence reports that local health plans are becoming involved with supporting affordable housing initiatives.

Also on the cutting edge, Healthcare Dive reports that the Food and Drug Administration has approved for marketing a digital pill called Abilify MyCite that tracks whether the patient ingests the medication.

Yesterday, the Centers for Medicare and Medicaid Services released proposed 2019 rules for the Medicare Advantage and Medicare prescription drug (Part D) programs. Here’s a link to the CMS Fact Sheet. Reuters reports that the Part D proposals would allow the plans to use limited pharmacy networks for opioid prescriptions and to share rebates more directly with consumers. The latter proposal is likely causing the industry palpitations. Oh and by the way, hey CMS where is the news release on 2018 Medicare cost sharing amounts and premiums??

CHIME announced that it has ended its patient ID challenge unsuccessfully.  Healthcare Dive explains that “Instead, CHIME will focus its efforts on creating a Patient Identification Task Force through its CHIME Healthcare Innovation Trust affiliate.”  That’s disappointing. How about using an intelligence free combination of characters.

Healthcare Dive also reports that “Having a primary care physician (PCP) care for their own patients in hospital settings may result in meaningful differences in care patterns and patient outcomes, according to a new JAMA study.” Well duh. The problem is translated the Dr. Welby scenario to a group practice scenario — see Quadruple Aim.

Finally the FEHBlog ran across this Centers for Disease Control website on cancer statistics across our great land.  Check it out.

While no one would expect to find good news in a federal agency’s annual financial report, the FEHBlog found good news in OPM’s fiscal year 2017 financial report which was posted today.  The report (p. 104) customarily includes recommendations from acting OPM’s Inspector General. One of the Inspector General’s standard recommendations during this decade has been to recommend that OPM advocate for carving out prescription drug benefit plan contracting from the health plans to OPM similar to TRICARE.  In a day when the government generally has been advocating coordination of care, the FEHBlog has found this idea to be counterproductive to say the least.  

Yesterday, as NPR reports, the President nominated Alex Azar to be Secretary of the Health and Human Services Department. Mr. Azar was deputy HHS Secretary in the George W. Bush administration and served as president of the U.S. branch of Eli Lilly pharmaceuticals. Mr. Azar’s nomination requires Senate confirmation.

The Postal Service reported its fourth quarter earnings today and according to Govexec.com the Postmaster General and the Postal Unions are urging Congress to enact the Postal Reform bill (H.R. 756) that the House Oversight and Government Reform Committee unanimously approved last Spring.  That bill would add a Postal Service Health Benefits Program to the FEHBP.

The Hill reports that

Speaker Paul Ryan (R-Wis.) on Tuesday said Republicans may need a short-term spending bill to prevent a government shutdown on Dec. 9.
Ryan said the House GOP’s goal was to pass a long-term spending bill by the end of the year, but suggested lawmakers may not be able to do so by a Dec. 8 deadline.
“We’re not talking about going into next year, we’re talking about getting it done this year,” Ryan said at a press conference on Tuesday. 

Mike Causey on Federal New Radio provides long time FEHBP expert Walt Francis’s take on the current Open Season.

Things you need to consider in your 2018 health plan include making sure your doctor is in the preferred provider option. Otherwise, you will need a new doctor, a new health plan or be prepared to pay a lot more for sticking with your favorite doctor by going out of network.
Your health plan’s catastrophic limit (the amount you will have to pay in a worst-case medical scenario) is often overlooked, but it is very important. If you or your family suffers a devastating medical event next year (illness or accident), the limit-to-you amount could be critical. Most bankruptcies in the U.S. are the result of medical bills. That shouldn’t happen to anybody in the federal FEHB program.
People should also check out plans with health savings accounts, which have been described as Roth IRAs on steroids. A little work. A lot of savings.

Of course the FEHBlog discussed HSAs on Sunday. The first point in the most important for all health plans because if you stay in network then your preventive care is “free” and you have ACA controlled out of pocket cost limits.

Tomorrow is the beginning of the Federal Benefits Open Season for next year.  The Wall Street Journal this weekend emphasized the tax benefits of enrolling in a high deductible health plan with a health savings account feature. This option is only available to folks who have not reached the age for Medicare eligibiity (and a federal court has ruled that you can’t opt out of Medicare Part A in order to maintain enrollment in an FEHB high deductible health plan with an HSA.

The HSA “is the most tax-favored savings vehicle in the tax code,” says Leo Acheson, a senior analyst at Morningstar Inc. who wrote a recent report about HSA. 

As with a traditional 401(k) or IRA, an HSA allows you to set aside money without paying federal or state income taxes on it. Money in HSAs grows tax-free and, if used now—or later—for medical expenses, can be withdrawn tax-free. In contrast, with a traditional 401(k) or IRA, income tax is paid on withdrawals. (Alabama, California, New Jersey and New Hampshire don’t provide a state tax deduction for HSA contributions and Alabama, California and New Jersey also tax HSA earnings.) 

Because of the HSA’s triple tax advantage—the upfront tax deduction, tax-free growth and tax-free withdrawals for medical expenses—experts recommend that those who can afford to contribute to both an HSA and a 401(k) kick in the maximum to both. 

For a 401(k), the current annual limit is $18,000 for people under age 50 and $24,000 for older investors—numbers that will rise to $18,500 and $24,500 in 2018. The annual caps for HSAs are $3,400 for individuals and $6,750 for families in 2017 and $3,450 and $6,900 in 2018—with those who are 55 or older permitted to kick-in an extra $1,000.

If you have a spouse who is 55 or older and has no coverage other than your FEHB plan, he or she can create his or her own HSA into which your spouse at least can make the spouse’s catch up contribution. The details are found in this Kiplinger’s article. (Of course, please check with your tax advisor.)

The Journal also had an article on how to get the most out of your HSA.

If your goal is to leave your contributions in the account for retirement, it is important to have a system to keep track of the money you spend out of pocket for current medical expenses. By saving your receipts, you will be able to file for reimbursement from your HSA at any time and create tax-free income in retirement. 

Before resorting to a shoebox or file cabinet to store your receipts, check whether your HSA provider offers an electronic repository; many, including Fidelity Investments, do. And make sure your heirs know where you keep the information. Spouses who are named as beneficiaries can inherit HSAs tax-free.

The FEHBlog has a high deductible plan with an HSA (and Mrs. FEHBlog now has her own HSA) outside the FEHBP.

Congress is in session on Capitol Hill this week. Here’s a link to The Week in Congress report on last week’s activities there.

The FEHBlog nearly levitated out his Lazy Boy when he read in the Wall Street Journal that

[A] new study [in JAMA Cardiology] analyzed data for 115,245 Medicare patients hospitalized for heart failure at 416 hospitals between 2006 and 2014. Hospitals chosen for the study were part of a separate American Heart Association effort to reduce heart failure readmission rates. 

Researchers compared hospital readmission and mortality rates before the Affordable Care Act passed in 2010 and after penalties took effect in late 2012.

One in five heart failure patients returned to the hospital within 30 days before the ACA passed. That dropped to 18.4% after the penalties. Mortality rates increased from 7.2% before the ACA to 8.6% after the penalties, or about 5,400 additional deaths a year for Medicare beneficiaries not in managed care plans.

How do you like them apples? OPM also strong incents FEHB plans to avoid hospital readmissions for any cause.

The FEHBlog was alarmed when he read the beginning of this Govexec.com article today:

Nov. 16 looms large for government leaders paying
attention to the 1998 Federal Vacancies Reform Act. The law stipulates
that 300 days after a president is sworn in, officials who have been
serving in an acting capacity since that time lose much of their
authority.

Of course, OPM has an acting Director, Kathleen McGettigan. The FEHBlog was relieved when he read a Congressional Research Service advisory to which the article links that

There are two distinct periods during which an employee may serve as an acting officer: (1) for a 210-day period, beginning on the date that the vacancy occurred; or (2) if the President nominates someone to that office, for the period that the nomination is pending in the Senate. There is no limitation of days on this second period—so long as a nomination is pending, an acting officer may continue to serve. But if no nomination is submitted to the Senate, the 210-day period governs the acting officer’s service.

Ms. McGettigan and presumably the bulk of people in her position fall into the second category which has no deadline on legal authority.

Speaking of Ms. McGettigan, the FEHBlog read on Bankinfosecurity.com that

The head of the U.S. Office of Personnel Management cites “audit fatigue” as a factor explaining why the federal agency that experienced a massive data breach in 2015 continues to come up short in securing its information systems. 

OPM Acting Director Kathleen McGettigan, in response to the OPM inspector general’s annual audit required under the Federal Information Security Modernization Act, points out that the OPM’s IG is one of several entities that audit OPM IT.  

“Each time an engagement commences, OCIO (Office of the Chief Information Officer) is obligated to expend time and resources locating responsive documents, responding to questions and, ultimately, replying to these multiple, sometimes overlapping duplicative audits,” McGettigan says. “We appreciate and understand the importance of these audits, but believe OCIO would benefit from an effort to achieve a more tailored, streamlined and coordinated approach from its various auditors.”  

Welcome to the club Ms. McGettigan because FEHBP carriers similarly are under strict scrutiny by OPM, its Inspector General, and other government agencies.

Given OPM’s interest in population health, it’s worth linking to the ARHQ post on how to take a closer – state by state – look at health care quality using the agency’s National Healthcare Quality and Disparties Report which was recently updated.

In ACA News, our favorite ACA expert, Prof. Timothy Jost, notes that the Internal Revenue Service is preparing to crack down on “applicable large employers” who fail to comply with the ACA’s employer share responsibility provisions.

In prescription drug news,

• Becker’s Hospital News reports that in 2018 CVS Health pharmacies will offer same day delivery of prescriptions in certain large markets ( Miami, Boston, Philadelphia, Washington, D.C., and San Francisco) and second day delivery in other markets.  These pharmacies will begin same day delivery in Manhattan beginning December 4. 
• Modern Healthcare reports that “Drug prescribers throughout the country should establish a seven-day supply limit for initial opioid prescriptions, and they should be written electronically to slow the abuse of the addictive painkillers, a group of pharmacies, pharmacy benefit managers and health plans wrote in a letter to President Donald Trump Wednesday.”
• In the same vein, an article in the New England Journal of Medicine discusses various approaches to “Addressing the Prescription Opioid Crisis: Advancing Provider Education and Collaborating with All Stakeholders.”
• Drug Channels analyzes employer-sponsored prescription drug costs as reported in Kaiser’s 2017 Employer Health Benefits Survey. 

Finally, Health Tech Magazine offers CIOs some approaches to introducing blockchain security measures to healthcare.

Yesterday the Government Accountability Office issued a report on the FEHBP titled “Enrollment Remains Concentrated Despite More Plan Offerings and Effects of Adding Plan Types Are Uncertain.” The Federal Times, Govexec, Federal News Radio, FedSmith, and Health Payer Intelligence all provide their perspectives on the report. 

GAO certainly is skeptical as to whether adding new plan types like regional PPO plans would improve competition in the FEHBP.  At least for the past two years, no new carrier has joined the FEHBP. In the FEHBlog’s view, the problem is that OPM does not offer an inviting competitive environment. OPM, for example, has introduced a new plan performance system which offer a limited reward to the HMO carriers and imposes a financial penalty on others.  The financial penalty necessarily is a deterrent to new carriers.