FEHBlog

The Affordable Care Act regulators released the final summary of benefits and coverage (“SBC”) and uniform glossary rule today. FEHB plans will be required to distribute this SBC for the first time during the 2013 Open Season, which begins in November 2013. This four doubled sided page summary is intended to help consumers select a health plan. However, the ACA regulators are not requiring that the SBC display the premium. Of course, the premium information could accompany the SBC.

The ACA regulators did not make substantive changes to the form or the uniform glossary on first glance other than to reduce the number of coverage examples from three to two. Here’s a link to the HHS Fact Sheet. All of the SBC templates and instructions can be found on this DOL website.

The ACA regulators also released FAQs for employers concerning several ACA provisions that kick in for 2014 – the automatic enrollment provision for new full time employees of employers with more than 200 employees, such as the U.S. Government, the employer shared responsibility provision, and the waiting period provision. Most of the FAQs focus on the question of defining a full time employee. The ACA regulators are accepting public comments on these issues until April 9, 2012.

The Wall Street Journal reports that UnitedHealth care is switching over to a new system for compensating network doctors that rewards doctors financially for avoiding hospital readmissions and doing a good job managing chronic illnesses.

In the last decade, the American Medical Association attacked the Ingenix usual, reasonable and customary fee schedule which health plans had used for decades as a benchmark for pricing out-of-network benefit payments. Ultimately, the New York State Attorney General joined the crusade. UnitedHealth which owned Ingenix settled the AMA lawsuit and New York investigation by agreeing to pay $300 million dollars and turn over its UCR fee schedules to a new non-profit called Fair Health. Health plans and insurers switched to another benchmark — the resource based relative value schedule that Medicare uses to reimburse doctors under Medicare Part B. (The dollar factor in this formula is adjusted by the statutory sustainable rate of growth formula that Congress always needs to patch and may now replace).  In the FEHBlog’s view, this was a good call because the AMA would be hard pressed to challenge the legality of the RBRVS. This week, the Kaiser Health News is reporting to its chagrin hat the RBRVS approach controls costs.

The AMA News is reporting that Rite Aid’s in store medical clinics are allowing customers to speak with a doctor over a video monitor — combining the retail clinic and telemedicine concepts.
 

A few years ago a group of federal retirees who were becoming for Social Security eligible sued for the right to opt out of Medicare Part A in order to remain eligible to contribute to a health savings account in their FEHB plan. Today, the U.S. Court of Appeals for the D.C. Circuit, affirming the lower court, held that people must accept Medicare Part A as a condition to receiving Social Security benefits, which was the federal government’s position. While this decision is a bit of a head scratcher (the FEHBlog has not read it yet), but the FEHB Program has dodged a bullet because Medicare Part A covers the hospital bills of most FEHBP annuitants over age 65.

Here’s a true tidbit for you — a Washington Post blogger put up a NARFE pie chart that breaks down the agencies where federal employees work. Over 50% of feds work at Defense, Veterans Affairs, and Homeland Security/

Here’s another tidbit. We all know that the “cloud” is a popular technology buzzword. Government Computer News tells us that a trending technology phrase is “Big Data.”  There are technies who now specialize in Big Data. GCN provided the following examples of Big Data–

Already, a variety of federal agencies are using big data
applications. The Office of Personnel Management is using a SAS analytic suite to scan data records from more than 400 health insurance
companies participating in the Federal Employees Health Benefits Program
for fraudulent claims and other irregularities. The SAS software is
also being used to analyze the millions of records in the CMS Chronic
Condition Data Warehouse, a repository for Medicare and Medicaid
research data.

GCE Federal is currently working on a project that will combine and
make searchable procurement data across the entire federal government. 
“Imagine if you could combine procurement data from every agency in the
government in one big database and have tools on top of it that would
allow stakeholders — from public users to government organizations — to
be able to go in there and slice and dice through procurement data in a
highly intuitive fashion,” said GCE Federal CEO Ray Muslimani.

From the sublime to the …..  The New York Times reports that the Congressional parties are battling over how to pay for an extension of the Medicare Part B patch or a replacement to the sustainable rate of growth formula. The current deadline is February 29. On March 1, a 27.4% cut in Medicare Part B payments to doctors occurs absent legislation. That’s a big hit to the doctors and the FEHB Program which would be subjected to a large cost shift due to the sizable cadre of annuitant enrollees with Medicare Part B coverage. Stay tuned.

The FEHBlog enjoyed the Super Bowl and hopes that everyone else did too. Congress is in session this week and the Presidents FY 2013 budget will be released next Monday.

While researching for this post, the FEHBlog ran across the comments that Essential Health Benefits Coalition sent to HHS last Monday. The FEHBlog previously has noted the Stop the Health Insurance Tax coalition, which recently advertised on the Politico Pulse, and the coalition seeking to repeal the Affordable Care Act’s medical device tax. The medical device tax and the $2500 annual cap on health care flexible spending accounts both take effect next year. The health insurance tax takes effect in 2014.  The Affordable Care Act has been good to the association industry.

The FEHBlog is surprised that Congress has not yet repealed the Affordable Care Act requirement that health plan members obtain a prescription in order to obtain reimbursement, e.g., from a flexible spending account, for an over-the-counter drug purchase. Of course, there’s a coalition to advocate for a repeal of that requirement, which doesn’t make a lot of sense to the FEHBlog, but the requirement has been in effect since January 1, 2011.

Health plans beware. The New York State Attorney General is on the warpath again. Last time, his target was the Ingenix system for setting out of network reimbursement rates. Now the target is out of date in network provider directories. The AMA News reports that  

In response to complaints from patients who were
frustrated by out-of-date physician directories, New York Attorney
General Eric Schneiderman has ordered a group of health plans [New York State subsidiaries of Wellpoint, EmblemHealth, and United Health Group] of to improve
their listings and pay back patients who were unexpectedly faced with
paying out-of-network rates.

The Medical Society of the State of New York “views this action by
the AG favorably,” said Moe Auster, the association’s vice president for
legislative and regulatory affairs. He said MSSNY members adopted a
resolution in 2010 calling on the state to require insurers to make
timely updates to their directories and penalize insurers for inaccurate
listings.

The article explains that the health plans expect cooperation from the providers to keep the directories up to date, but no matter.

Govexec.com reports on OPM’s problems in processing federal retirement claims. The other day, the FEHBlog was speaking with a veteran Congressional staffer who is expecting a wave of staffer retirements next year on Capitol Hill because Congress and many staffers shift to the health insurance exchanges in 2014. Retiring in 2013 will allow them to preserve their FEHB coverage.

Kaiser Health News has a brief survey of comments submitted to HHS on the Essential Health Benefits bulletin. Quite a hash.

Modern Healthcare reports that the AMA is appealing to HHS Secretary Sebelius to back off on ICD-10 code set implementation. The AMA complains that doctors are facing an onslaught of regulatory mandates. The AMA suggests that HHS has an opportunity to ease the burdens on physician practices by halting the implementation of ICD-10 and calling on appropriate stakeholders, including physicians, hospitals, payers to assess an appropriate replacement for ICD-9 within a reasonable time frame. Hey the ICD-11 is coming out in 2014! But seriously the problem is that Congress decided in HIPAA to embed technology in law. However, that ship has sailed. If the AMA prevails on this one, it would be a sea change (to continue the analogy).

Today was the deadline for commenting on the HHS Essential Benefits Bulletin, and AHIP submitted an interesting comment letter. The FEHBlog was puzzled by the Bulletin’s statements that state benefit mandates don’t add that much to health plan costs. The AHIP comments blow that statement out of the water. Fortunately, federal law exempts FEHB plans from those state benefit mandates. FEHB plans, of course, are subject to federal mandates, such as those created by the Affordable Care Act.

OPM has informed agencies to consult a recent IRS notice giving employers a heads up on compliance with the Affordable Care Act requirement that 2012 W-2s include a block informing the employee about the cost of employer-sponsored health care coverage, including FEHBP coverage.

Modern Healthcare reports about a sobering Congressional Budget Office report projecting that federal healthcare outlays will double over the next decade.

A Wellpoint press release today announced that  “Medical and pharmacy benefits managed by Wellpoint’s affiliated [Blue Cross Blue Shield] health plans are linked to lower medical costs of $8 to $16 per employee monthly compared to those without an integrated pharmacy program, according to an independently verified analysis of members in WellPoint’s health plans.”  This is latest study militating against OPM’s legislative proposal to carve out FEHBP prescription dru contracting to the agency.

Two articles tickled the FEHBlog’s funny bone:

• The Wall Street Journal’s Health Blog points out that doctors represent a large percentage of the the fabled 1% that the Occupy Wall Street movement has assailed.  “Fully 27% of doctors are     1%ers — the highest percentage of all occupations, including lawyers.
• The AMA News reports about the one diagnosis that patients miss — “cyberchondria.” In other words, the 1% is growing frustrated with the members of the 99% who attempt to self diagnosis their illnesses on the internet.

Congress is in session this week. On Wednesday at 2:30 p.m. the Oversight and Government Management subcommittee of the Senate Homeland Security and Governmental Affairs Committee will hold a hearing on ensuring timely and proper federal employee retirement payments by OPM.

Kaiser Health News notes that on Friday the Bipartisan Policy Center issued a report on what needs to be done to achieve the promised cost efficiencies of electronic medical records.

Reuters UK wrote a blue sky piece about the options available to Medco and Express Scripts if the fedeal government blocks their merger. The FEHBlog thinks that outcome is more likely than not.

The Wall Street Journal reported this morning that Wellpoint and Aetna are offering more money to primary care doctors in their provider networks who are willing to engage in more care coordination efforts.  “The ‘scale is so much bolder than things we’ve seen,’ said Paul Ginsburg, president of the Center for Studying Health System Change, a Washington nonprofit group. “‘This isn’t an experiment.'” Sounds like a win-win.

Everytime the FEHBlog looks at the HHS website, it seems like the Administration is throwing more and more Affordable Care Act and HITECH Act dollars at the medical community. It’s gratifying to see these targeted actions by insurers.

On the preventive care front, USA Today reports that the Centers for Disease Control is concerned that the number of Americans being screened for breast, cervical, and colon cancer continued to fall below national targets in 2010. It will be interesting to see if the percentages trend up because the Affordable Care Act makes the testing “free.” The AMA and AARP has released a new Medicare Preventive Services Brochure.

Aetna announced a new initiative to support dentists in adopting the U.S. Public Health Service’s tobacco cessation guidlines. What a good idea!

Health Data Management reports on the American Medical Association’s quixotic campaign to stop implementation of the ICD-10 code sets next year. CMIO tells us that the AMA’s Executive has written to the House Speaker John Boehner about the issue. The AMA complains that it’s an unfunded mandate. Sure the code set implementation will be disruptive to doctors but insurers have been implementing the new code sets for a couple of years due to a government mandate. The only government support is HHS allowed a portion of the ICD-10 conversion costs to be treated as benefit expenses for purposes of the new federal minimum loss ration. Where was the AMA in 2009 when it could have stopped the train before it left the station?

Finally Modern Healthcare reports that the Federal Trade Commission has sue to block long term care pharmacy Omnicare’s bid to buy competitor Pharmerica Corp. That can’t be encouraging news for Express Scripts and Medco.

Medscape Today is reporting that the American Medical Association and 109 other medical societies are urging Congress to use the peace dividend to fund a credible replacement for the sustainable rate of growth formula.  That formula is intended to set adjustments to Medicare Part B reimbursements to doctors but Congress has prevented the use of the formula for several years because it would slash those reimbursements.

Employee Benefit News reports that an Emory University researcher told the National Academy of Health Underwriters that  “The key,” [to saving costs on]  those whose lifestyle may lead to chronic diseases, such as being overweight, “is not to charge them more but engage them and keep them healthier, keep them out of the clinic, keep them from being readmitted to the hospital.” Hey, it’s a lawyers job to belabor the obvious.

Meanwhile the AMA News complains that patients are confused when the preventive visit is “free” in accordance with the Affordable Care Act but the treatment of problems identified during the visit isn’t. The solution apparently is to make everything free to the patient. This, of course, is the basic problem — health insurance isn’t insurance — it’s a price support for the medical industry.

Both Houses of Congress will be back to work tomorrow. Just about five weeks until the current two month tax extenders law, including the Medicare Part B doctor reimbursement patch, expires (February 29 — Happy Leap Year)

The Wall Street Journal is offering opposing perspectives on various health policy issues. One of the issues is whether there should be a universal patient identifying number. When Congress enacted HIPAA, it required HHS to issue several identifying numbers — including numbers for health plans, employers, doctors, and patients. HHS issued the uniform identifiers for employers and health care providers. But 15 years after HIPAA’s enactment, HHS has not adopted a health plan identifier (although thanks to the private marketplace those identifiers are out there). In the late 1990s Congress due to privacy concerns barred HHS from using federal funds to adopt a uniform patient identifier. However, the federal government under the HITECH Act of 2009 is now hurling money at doctors so that they will adopt health information technology. The federal government also has plans for health information exchanges and an electronic patient information finding service so that my doctor would be able to find who else holds electronic health records on me. How can all of this work without an identifying number? This strikes the FEHBlog as a train that has left the station.

The Leapfrog Group for patient safety has posted report cards on the progress that major health insurers are making toward the Group’s policy objectives.

The FEHBlog is still experiencing internet difficulties at home.

OPM announced on Wednesday that it is requiring FEHB plans to offer “Blue Button” technology to their members in mid-March 2012. “Blue Button allows patients to see, download and keep their personal health data by clicking the ‘Blue Button’ on a secure Internet site.” The Veterans Affairs healthcare system successfully has implemented the Blue Button for its patients. Although this strikes the FEHBlog as a good idea, the fly in the ointment is that while the VA delivers healthcare to patients, the FEHBP delivers benefit payments to enrollees. Now this is not black and white. Kaiser Permanente  is an example of a health care provider that participates in the FEHBP. It will be interesting to see how enrollees react to this new technology.

Standard and Poors reported yesterday that

The S&P Healthcare Economic Composite Index indicates that the average per capita cost of healthcare services covered by commercial insurance and Medicare programs increased by 5.13% over the 12-months ending November 2011. This is a decline from the +5.29% annual growth rate posted for October 2011.

As measured by the S&P Healthcare Economic Commercial Index, healthcare costs covered bycommercial insurance plans increased by 6.96% over the year ending November 2011, down from the +7.10% reported for October. Growth rates in Medicare claim costs rose by 2.37%, as measured by the S&P Healthcare Economic Medicare Index, down from the 2.55% reported for October.

The S&P Healthcare Economic Professional Services Medicare Index also dropped from +4.15% in the year ending October 2011 to +3.62% in November. The S&P Healthcare Economic Hospital Medicare Index increased slightly to +1.33% in November from its +1.28% October value.

That growth rate is somewhat higher than the CMS actuary report that health care costs increase about 3.9% in 2010.

In less than encouraging news related to this topic, Medscape reports that “Most Medicare demonstration projects aiming to reduce costs and improve the quality of care — prime goals of healthcare reform — miss their mark, according to a new study from the Congressional Budget Office (CBO) published online Wednesday.” And the AMA News reports that medical specialists are hiring laid off drug representatives to sell their services to primary care physicians.