FEHBlog

Yesterday, the House Oversight and Government Reform Committee approved the bipartisan 2017 Postal Reform Act (H.R. 756) by a voice vote. The bill would create a separate Postal Service Health Benefits Program within the FEHBP effective January 1, 2019. The bill remains pending before the Ways and Means and Energy and Commerce Committees, but this was a big boost toward final House and Senate passage.

Also yesterday, the President released a budget “blueprint” for discretionary federal government expenses. A complete budget with income and mandatory spending, e.g, Medicare, Medicaid, Social Security, will be issued in May. In that regard, earlier this week the President issued an executive order seeking a federal government reorganization according to Federal News Radio.

Continuing federal appropriations funding requires Congressional action next month. The current continuing resolution expires on April 28. Furthermore, the Hill reports that “Lawmakers will have until sometime this autumn to raise the debt ceiling before the Treasury runs out of ways to make essential payments, putting the nation at risk of its first-ever debt default.”

Finally Federal News Radio also reports that President Trump withdrew President Obama’s nomination of Elizabeth Field to serve as OPM Inspector General.

Erin go bragh.

The American Health Care Act cleared the House Budget Committee on a 19-17 vote today. (The FEHBlog wrote this on March 16 but it wasn’t posted until March 17.)  The Wall Street Journal reports that “The bill will now proceed to the House Rules Committee, which will vote and determine the rules governing the process to alter it on the House floor.”

Lest it pass us by, let’s not forget that it’s National Patient Safety Awareness Week. ECRI Institute has created a list of the top ten patient safety concerns:

Information Management in EHRs
Unrecognized Patient Deterioration
Implementation and Use of Clinical Decision Support
Test Result Reporting and Follow-Up
Antimicrobial Stewardship
Patient Identification
Opioid Administration and Monitoring in Acute Care
Behavioral Health Issues in Non-Behavioral-Health Settings
Management of New Oral Anticoagulants
Inadequate Organization Systems or Processes to Improve Safety and Quality

Speaking of which, the FEHBlog’s attention was drawn to this EHR Intelligence article about a “new study published in the Journal of the American Board of Family Medicine found patient-reported self-assessments and provider-reported assessments of patient health rarely align.”  The article explains that

“A closer look at the reasons given by patients and physicians helps explain that discordance,” the researchers wrote. “We found that physicians tended to focus on disease in their reasoning for all patients, whereas those patients with excellent and very good self-reported assessments focused on feeling well. In medicine, wellness is often considered the absence or prevention of disease, but other concepts within wellness, such as happiness and contentment, may be equally or more important to patients.”
While self-reported assessments are considered an important complement to provider-reported information in EHRs, small biases like emotional wellbeing potentially impacts patient opinion of personal physical health.
Because providers and patients appear to occasionally consider different factors when assessing a patient’s health, researchers believe more face-to-face discussion is imperative to closing gaps in knowledge of patient information and forming a more accurate overall assessment of health.

The FEHBlog guesses this ties back to the first patient safety concern that the ECRI Institute named.

Finally, here’s a link to an interesting Workforce.com on the effective use of carrots and sticks in employee wellness programs.

The important markup is scheduled for tomorrow at 10 am, not today. In the meantime, the FEHBlog recommends reading Avik Roy’s Forbes article on the CBO report.

This afternoon, the Congressional Budget Office issued its report on the American Health Care Act. Here’s a link to the report. The House Budget Committee meets on Wednesday as noted in yesterday’s post.

Congress remains at work on Capitol Hill this week. The Senate is expected to confirm Seema Verma to be Administrator of the Centers for Medicare and Medicaid Services.  The Senate Health Education Labor and Pensions Committee will hold a confirmation hearing for the President’s latest nominee for Secretary of Labor, R. Alexander Acosta, on Wednesday afternoon. These are both significant positions in terms of ACA administration.

Modern Healthcare features an interesting article on the state of the burgeoning telehealth market. The large vendors are turning their attention to serving hospitals and health systems. It’s always seemed like a no brainer to the FEHBlog that telehealth services could help avoid unnecessary readmissions. But it appears that hospitals are using telehealth services to replace staff for inpatient services. Time marches on. We get closer to the Jetsons.

The FEHBlog et ux (look it up) have been listening to an audiobook of Malcolm Gladwell New Yorker articles. Today we heard Mr. Gladwell who narrates his own work describe the difference between puzzles and mysteries.

The national-security expert Gregory Treverton has famously made a distinction between puzzles and mysteries. Osama bin Laden’s whereabouts are a puzzle. We can’t find him because we don’t have enough information. The key to the puzzle will probably come from someone close to bin Laden, and until we can find that source bin Laden will remain at large.
The problem of what would happen in Iraq after the toppling of Saddam Hussein was, by contrast, a mystery. It wasn’t a question that had a simple, factual answer. Mysteries require judgments and the assessment of uncertainty, and the hard part is not that we have too little information but that we have too much. The C.I.A. had a position on what a post-invasion Iraq would look like, and so did the Pentagon and the State Department and Colin Powell and Dick Cheney and any number of political scientists and journalists and think-tank fellows. For that matter, so did every cabdriver in Baghdad.
The distinction is not trivial. If you consider the motivation and methods behind the attacks of September 11th to be mainly a puzzle, for instance, then the logical response is to increase the collection of intelligence, recruit more spies, add to the volume of information we have about Al Qaeda. If you consider September 11th a mystery, though, you’d have to wonder whether adding to the volume of information will only make things worse. You’d want to improve the analysis within the intelligence community; you’d want more thoughtful and skeptical people with the skills to look more closely at what we already know about Al Qaeda. You’d want to send the counterterrorism team from the C.I.A. on a golfing trip twice a month with the counterterrorism teams from the F.B.I. and the N.S.A. and the Defense Department, so they could get to know one another and compare notes.
If things go wrong with a puzzle, identifying the culprit is easy: it’s the person who withheld information. Mysteries, though, are a lot murkier: sometimes the information we’ve been given is inadequate, and sometimes we aren’t very smart about making sense of what we’ve been given, and sometimes the question itself cannot be answered. Puzzles come to satisfying conclusions. Mysteries often don’t.

Drug pricing falls into the mystery category. Indeed all health care pricing falls into the mystery category. But drug pricing is a peculiar mystery.  That’s why the FEHBlog appreciate the Drug Channels blog which lately dicusses a Johnson & Johnson subsidiary pricing transparency report. He gives it two thumbs up.  Check it out.

Here’s a link to the Week in Congress’s one page report about what happened on Capitol Hill this week.  The Wall Street Journal reports that after two lengthy mark up sessions the House Ways and Means and Energy and Commerce Committees cleared the American Health Care Act for Budget Committee consideration next Wednesday. We should have a Congressional Budget Office score before then. The House leadership’s objective is to bring the bill to the House floor for a vote during the week of March 19. The bill would then head to the Senate for consideration under the reconciliation act rules which allow for Senate passage with 51 votes.  It’s not clear at this point what will happen in the Senate.

The Journal further reports that the House leadership will introduce a broader ACA replacement bill this month which the Senate would consider under regular order. Regular order allows for a filibuster which can be broken with sixty votes. The FEHBlog has read that there are other approaches which would allow for the Senate to get past a filibuster by the passage of time. Of course there is a Congressional Research Service report which discusses the two speech limitation which is an alternative to the sixty vote cloture rule.

Finally according to the Journal report, there are administrative “actions that the Trump administration can take on its own [under the terms of the ACA] . The administration has already issued rules intended to shore up the individual insurance market until the GOP vision of a new health system is enacted. Other changes may include giving states more flexibility in running Medicaid programs and allowing insurers to sell policies without maternity care or other benefits now required under law.”  The FEHBlog views this as loosening the choke chain that the ACA placed on insurers. He looks forward to this stage because it could simplify life for FEHB carriers.

The FEHBlog ran across this farewell address from the CEO of the Robert Wood Johnson Foundation  and because it’s upbeat here’s the link. Have a good weekend.

Yesterday, the House of Representatives began consideration of the American Health Care Act. House Speaker Paul Ryan explains that House consideration of the bill will be a multi step process leading to consideration on the House floor.

This week, the Energy and Commerce Committee and Ways and Means Committee are holding markups to consider their portions of the bill.  Next [after the Congressional Budget Office score is released], the work of these two committees will go to the Budget Committee to be considered as one bill. After that, the legislation will go to the Rules Committee [before reaching the House floor]. 

The Speaker emphasizes that the bill has been under development for over a year. Prof. Timothy Jost dissects the bill in Health Affairs.  The FEHBlog who appreciates the Goldilocks story takes heart in the Washington Post’s subheadline this morning that the bill is under attack from the left and the right.

OPM in its 2017 and 2018 call letter for benefit and rate proposals encouraged FEHBP carriers to adopt telehealth and value based insurance design. For that reason the FEHBlog calls readers attention to recent studies on those topics:

• A Health Affairs study “on the impact of a value-based pharmacy benefit on medication adherence found that offering free chronic disease medications maintained patients’ levels of adherence even after switching to a health plan with a deductible.”
• Another Health Affairs study on telehealth services finds that the services at this stage at least are a convenience and do not bend the cost curve down.  This comes as no surprise to the FEHBlog. Nevertheless Healthcare Finance identifies some useful conclusions from the study

The House of Representatives leadership released the American Health Care Act which is intended to repeal large parts of and replace the Affordable Care Act.

The bill does not include a provision that would tax employer sponsored premiums in excess of a dollar threshold as the FEHBlog discussed yesterday. For that reason, the bill retains the ACA’s Cadillac tax but pushed the effective date back from 2020 to 2025.

With respect to the FEHBP, the bill principally would preserve the ACA’s age 26 coverage provision, lift the statutory cap on flexible spending accounts (OPM would have to agree to increase the cap), lift the exclusion on HSA, HRA, and FSA reimbursement of over the counter medicines and increase maximum annual contributions to health savings accounts. The changes generally would take effect next year.

The bill would zero out the individual and employer mandates. The bill also would eliminate virtually all of the ACA imposed business and personal taxes beginning next year except for the Cadillac tax and the PCORI fee unfortunately.

The bill would provide an age rated, and income restricted advanceable tax credit to purchase individual health insurance. It would create a role for health insurance agents. The bill would permit the credit to be use to purchase health coverage which is not ACA compliant, e.g., catastrophic coverage. The bill’s provisions must pass muster from the Senate parliamentarian in order to be treated as a budget reconciliation act which can’t be filibustered in the Senate.

The Ways and Means Committee will mark up the bill on Wednesday morning.  At the same time on Wednesday, the Energy and Commerce Committee will consider the budget reconciliation aspects of this legislative action.

Congress remains in session this coming week on Capitol Hill. Here’s a link to the Week in Congress’s one web page account of last week’s activities on the Hill.  The House Oversight and Government Reform is holding a business meeting Wednesday morning to mark up a few bills. The postal reform bill is not one of them.  We shall see whether the Republican health care re-reform bill surfaces this week.

The FEHBlog hopes that the Republicans unveil a bill that will attract some support across the aisle. There is no doubt that the ACA needs to be overhauled. The last thing that the FEHBlog wants to see is Obamacare replaced by Trumpcare or Ryancare. Some form of bi-partisan bill would help insure a desirable degree of  permanency in the new legislation.

The FEHBlog was pleased to hear a radio interview with House Speaker Paul Ryan in which he indicated that the House reform bill will level the tax playing field.  An idea that the FEHBlog has seen floated around is to impose income tax on annual health insurance premiums above $8,000 for self only and $26,000 for other than self only. That assumes an average family size of 3.25.

Because the average family size in the FEHBP is closer to two people than 3.25 people, the average FEHB premiums for self only currently are close to $8,000 but the average premiums for other than self only are well below $26,000 annually. It would be a lot more equitable to allow all lower and middle income taxpayers whether covered under group or individual plans to continue to enjoy the exclusion while all higher income people lose half of the exclusion like self-employed business owners do today.

While we wait to see what develops, take a look at this Robert Woods Johnson Foundation tool which allows you to compare health costs among 500 U.S. cities.